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Poetic license: writing poetry as a way for medical students to examine their professional relational systems.

Medical educators and researchers have studied poetry by medical students as a potential source of information about the socialization process in medical education and students' views about salient clinical issues. One previously uninvestigated area is the examination of medical student poetry for insights into how students experience and understand the professional relational systems in which they participate during their training. In this article, the authors examine a series of poems written by medical students for insights into the students' relationships with patients, patients' families, and supervisors. Detailed analyses demonstrate how students use various elements of poetry, such as vivid detail, metaphor, point of view, and emotional expression, to explore these relation ships. The authors conclude that writing poetry may exert a healing influence on students and appears to be one way students can make emotional sense of the different relational systems they encounter over the course of training.

Keywords: medical student poetry, poetry and medicine, medical education, doctor-patient relationship


Tell all the Truth but tell it slant.--Emily Dickinson

There is increasing interest on the part of medical educators in the poetry of medical students. Many medical schools publish journals containing creative writing by students, and there are several medical school literary contests recognizing student poetry (e.g., the William Carlos Williams Poetry Competition, sponsored by the Human Values in Medicine Program of the Northeastern Ohio Universities College of Medicine). Analyses of student writing, including poetry, have framed such writing as a way to reflect on and come to terms with the socialization process medical students undergo. Poetry can assist in students' "struggle to sustain their idealism" (Poirier, Ahrens, & Brauner, 1998, p. 473). It also appears to be a good vehicle for the expression of individual students' perceptions, concerns, and feelings.

Researchers have examined medical students' original writing, including poetry, to understand specific themes and concerns related to medical education (Rucker & Shapiro, 2003). Representative themes include role confusion, professional identity, medicine as a calling, physician privilege and power, the limits of medicine, and identification with the patient (Hatem & Ferrara, 2001). Similar themes derived from medical students' storytelling were identified earlier by Anderson (1998), who also emphasized the capacity of this process to heal student confusion and suffering. In an insightful article, Henderson (2002) analyzed students' poetry to explore their evolving views of death and dying and noted their eagerness to avoid dehumanization of the dying process. One medical student anecdotally reported using poetry to explore her personal struggles with illness as well as to improve communication with her physician (Goldstein, 1997).

Medical students are both moved and troubled by various aspects of the professional relational systems in which they are involved as part of their medical education (Suchman et al., 2004). When they are asked to reflect on these experiences, they express penetrating insights as well as significant difficulty adapting to medical culture (Branch, 1998). Reports indicate that specific forms of writing, such as critical incident reports, are effective as a method of reflection (Brady, Corbie-Smith, & Branch, 2002; Branch, Lawrence, & Arky, 1993), as are other approaches, such as support groups (Novack et al., 1997), small group discussions (Branch, 2000), and individual debriefing with faculty (Baernstein & Fryer-Edwards, 2003). One previously uninvestigated area is what students' poetry specifically can tell us about how they experience, understand, and make sense of their professional relationships.

Poetry may offer students certain unique possibilities for reflection that are less evident in more analytic, logical forms of writing or in verbal communication (Shapiro, 2004). Sometimes indirection in poetry, the "slanted" approach to which Emily Dickinson referred, allows learners to more easily examine intangible aspects of their relational experiences in medical school. Issues that seem straightforward when organized through the well-defined and prescribed formulas of the case presentation yield other interpretations when explored in verse. The often ambiguous, complex, and imprecise nature of the quandaries students encounter in their professional relational systems makes exclusive reliance on logico-scientific reasoning inadequate to resolve their concerns. Specifically, we believe that poetry's often intimate use of "voice," its particularity, its ability to express multiple, alternative perspectives, its predilection for metaphor, and its capacity to evoke emotion all contribute welcome insights into how medical students view and resolve the professional relationship systems in which they are embedded.

We now turn to a consideration of three relational systems within which medical students regularly function. Through an analysis of student poems in each relational category (all poems discussed are included in the Appendix), we identify issues that students consider to be important regarding these systems: For example, are patients the teachers and companions of students or their enemies? Are the perspectives of medical personnel and family members incompatible? Are attendings and residents role models or betrayers of student trust?

Johanna Shapiro reviewed a total of 171 poems written by third-year medical students over a 4-year period. These poems were written as part of a required humanities component in both the third-year internal medicine and pediatric clerkships. Students were instructed to use a creative medium (poetry, personal essay, painting, handicrafts, etc.) to reflect on a patient encounter or other medical event they had either experienced or observed that was disturbing or memorable to them. Instructions were intentionally kept general and nonspecific to give students as much latitude as possible in interpreting the assignment. Students were told in advance that they would be expected to share these original works in a small-group setting facilitated by an interdisciplinary team of a physician and a psychologist. Students were encouraged to reflect honestly but not to write or create at a level that would be embarrassing or too personal. Students were also cautioned that writing about or otherwise examining their thoughts and feelings about patients, family members, or attendings only represented one perspective (i.e., their own) and that all these stakeholders in the medical system had their own point of view and their own stories to tell. The point of the creative projects was not to concretize the students' experiences but rather to explore, refine, and perhaps reconsider them. During the time period under study, students submitted 704 creative projects. Of these, 24.29% were poems, a figure that matches well with an earlier report (Rucker & Shapiro, 2003).

In the group sessions, students first shared their work, followed by discussion of whatever issues were raised. These sessions were often intense, with students sometimes expressing anger or breaking into tears. However, the sessions proved to be a useful place to help students first identify their feelings and then validate their perceptions. Informal feedback from students suggested that they felt less isolated and less inadequate after these sessions and were relieved to have been able to examine difficult issues in a supportive, nonjudgmental environment. Faculty cofacilitators occasionally spoke with a given student after the session if it appeared that the student needed further debriefing or guidance. At the start of each humanities session, students were reminded that the medical school's staff psychologist, a well-known and highly regarded figure, was al ways available to process the stresses and strains of medical training with students. Student projects were not graded, but each was reviewed by a faculty member and commented on in a way that both supported the student and encouraged further reflection.

Using a modification of a coding system reported in previous research (Rucker & Shapiro, 2003), Johanna Shapiro categorized all poem projects according to three major professional relational categories, further subdivided into 13 categories as well as an "other" category for poems whose themes were irrelevant to the focus of this article. A thematic breakdown of all poems reviewed is included in Table 1. Coding was determined primarily by face validity; that is, a poem that portrayed a physician supervisor as hostile and uncaring was classified first in the category "student-attending relationship" and subsequently in the subcategory "attending as anti-role-model." Each poem was coded only once, according to its predominant emphasis. About three quarters of these poems dealt with professional relational systems in some form. From these 127 poems, we selected a handful that we judged to best illustrate a particular point. We make no claim that the poems discussed below are in any quantitative way "representative" of student writing. However, as we discovered, the themes that these particular poems address preoccupied many students, either in their own writing or in subsequent group discussions. The modes and methods of grappling with the issues are unique to each poem, but in their particularity they also touch on universal concerns. All students listed in this article gave explicit written permission to have their work and name included and understood that the article was intended for publication in a professional journal. All students also had an opportunity to review the manuscript and make any suggestions or changes they wished before submission. Finally, it should also be pointed out that these poems do not express broad philosophies of medicine or ingrained characterological traits of students; rather, they are specific responses to specific situations at an early point in the students' learning process.


Students identified developing an appropriate professional connection with patients as a crucial goal of their clinical education. At one extreme, students perceived their patients as teachers and guides. At the other end, they imagined their patients as adversaries who threatened their well-being and sense of control. Ultimately, many students, although sometimes confused and overwhelmed by the responsibility of clinical care, through their poetry expressed strong solidarity with patients.

Students often saw their patients as their best and most important teachers. A poem that illustrates this point well was provided by Maryam Bahadori. She writes of Mr. C., a patient she encountered at a Veterans Affairs (VA) hospital. In the first line of her poem, she underlines his bizarrely miniature size and weight, perhaps intimating that he is a midget or in some way a freak. The next line provides the explanation--Mr. C. has had below-the-knee amputations of both legs. What follows is a dizzying list of the patient's serious and life-threatening diseases that points to the apparently obvious conclusion: "There wasn't much left of him." But then the narrator takes a second look and questions her own assumptions. When she considers more closely, there is a lot more to Mr. C. than first appears. He is funny, daring, impish, the "VA resident social butterfly" who, despite the ravages visited on his body, is a large and delightful presence. Mr. C. teaches his awe-struck student to smile in the face of adversity and to have the courage to embrace life even when confronted by death. With a backward nod toward the shocking amputation image, the narrator moves resolutely forward to the real conclusion of the poem. She revives the image of absent feet, only this time they are metaphoric, as Mr. C scoots around in his electric wheelchair, "one foot straddling life, the other death."

This poem specifically addresses the issue of perspective and assumptions. It takes advantage of the particularity of metaphor and synecdoche (the substituting of a part for the whole) to guide both student and reader to a deeper understanding of this patient. The poem calls up emotions of admiration, caring, and respect, and we feel humbled by the courage embodied in the final lingering image. Both writer and reader are more at peace with Mr. C. by the end of the poem and better able to appreciate his humanity. Through this poetic reflection, the student redefines her own conclusions and voices a perspective that is much more than a strictly medical summing up of the patient.

Students also sometimes experienced a broken student physician-patient relationship. In such poems, the relationship between doctor and patient appeared damaged, perhaps severed. The patient was conceptualized as the enemy. A poem written by Micheal Chao in the voice of a third-year medical student complains about noncompliant and demanding patients. The student poet asks rhetorically, "Why should I care if the patient doesn't?" The tone is both frustrated and sarcastic: "No change in symptoms, gee I wonder why/ Maybe if you listened and tried you'd feel better." The poem concludes with a statement of rejection: "Don't come to me for help." Although poems such as this were in the distinct minority, they represent an important internalization of one dimension of the informal curriculum, which encourages students to categorize patients into good and bad, cooperative and difficult, so that it may seem justifiable to at least fantasize about rejecting such patients. During discussions, many students admitted harboring similar feelings.

In this case, the writer addresses patients directly in the second person "you," placing patients in opposition to the professional solidarity expressed through the student's identification with the healthcare team. As noted above, the emotions expressed in this poem are familiar to medical students, residents, and physicians, although they rarely have a formal outlet. Although painful to read, the poem represents an important first step in recognizing and acknowledging the negative underbelly of medicine--the possibility of resentment and hostility toward those whom the profession intends to help. Without this honest emotional ownership, such feelings run the risk of contaminating the doctor-patient relationship in more indirect ways by leaking unconsciously into interactions and clinical decision making (Smith, 2002; Stein, 1985).

"Metamorphosis," by Michael Doo, describes a transformative process in the student's relationship with his patient. The student first encounters the patient through the medical chart, vital signs, physical findings, and differential diagnosis. The jargon, tests, and procedures, the "impenetrable" exchanges among the medical team about the patient, all serve to wrap the patient in a cocoon separating her from the student. The student appeals directly to the patient ("Help me!") as he resists the urge to reduce her to a differential diagnosis. He pleads to be admitted into knowledge of "the irrelevant, the maybe-not-so insubstantial" that will enable him to rehumanize his patient. The poem concludes with another appeal directed toward the patient. In an ambiguous but inspiring image that suggests perhaps escape, perhaps soaring, or both, the student urges that he and the patient face the world together, whether for a single medical encounter or for a lifetime.

Doo's poem effectively uses metaphor (the insulating "cocoon" of the chart) and metonymy ("to uplift print into humanity") to convey the depersonalization inherent in medicalizing the patient as well as the almost godlike challenge ("construct a being out of labs") of restoring the patient to three-dimensional existence. The author also recognizes that the patient's voice has become first remote, then silenced. By using the intimate second person "you," the author engages not only the patient but the reader in this quest and thereby creates a strong emotional investment in the outcome. The evolution of voice from "you" and "I" to "we" brings a sense of relief, even joy, as the rifts between student physician and patient are repaired. Like Bahadori and in contrast with Chao, Doo makes a conscious decision to align his voice with that of the patient rather than the medical establishment.


Much less frequently, students used poetry to explore their relationships with patients' family members. Generally, this type of poetic investigation emerged from reflections on the pediatric clerkship, where it is obviously more difficult to avoid the familial implications of disease. Medical education generally pays only cursory attention to the familial context in which individual illness inevitably occurs. For this reason, students are often baffled when they find they must deal not only with the patient but also with the family's issues, concerns, and even presence.

"A Mother's Will," by Susie Shin, shows the simultaneous frustration and respect that exists between parents and medical personnel. In a dialogue between a mother and unidentified medical staff, we learn about the objective "truth" that medical science provides as well as about a parent's unwillingness to give up on a difficult pregnancy or the multiply disabled infant that results. The dialogue proceeds on parallel tracks, and it appears that neither side is listening to the other. There is no resolution, no coming together, not even for the good of the child. Indeed, there is no agreement between parent and expert about what "the good of the child" means.

The structure of this poem, which uses italics to indicate alternate voices, represents visually the disparity between parental and professional views of the child patient. The brevity of each line, seemingly pared down to its essence, serves to emphasize the intractability of the opinions expressed. The voices, although they never resolve their differences, are clearly delineated, so that each perspective can be more easily identified and understood. Implicitly, the medical student positions herself between both voices, suggesting that she empathizes with each party's position. The poem represents a beginning step toward legitimizing the multiple voices present in any medical situation, without prioritizing one over the other because of authority or expertise.

Another perceptive poem, "Dueling Chief Complaints," by Mary Alice Kalpakian, presents an anorexic girl who thinks she is too fat, a mother who knows her daughter is too thin, and a medical student driven by her own obsession not to miss a medical zebra. The poem affixes blame for the difficulties of this situation on a culture permeated by Madison Avenue standards of physical perfection. The tragedy here is that there is no medicine or Band-Aid the student can offer to save this "piece of fine china" from breaking. The student must confront her own helplessness at the limits of medicine to fix broken girls, broken mothers, and broken societies.

Kalpakian's poem relies on creating multiple conflicting voices to incorporate perspectives of patient, family, and student into the medical encounter. The clever title uses a metaphor of conflict to stress the lack of resolution in the exam room. The student poet's skillful representation of each voice recognizes the underlying theme that unites them--each party has a "chief complaint"; therefore, each party is suffering. The metaphors used ("spider web of Madison Avenue," "teetering piece of fine china") stimulate emotional responses of entrapment, struggle, anxiety, and concomitant urges to protect and save. The helplessness of the student mirrors that of mother and child, victimized by powerful profit-driven social forces. The poem does not offer simple answers but does provide much-needed insight into a complex social problem.


As their clinical training progressed, students began to realize that they somehow had to negotiate the tricky triangle of student-attending/resident-patient. Most initially assumed they would have an uncomplicated, straightforward, even nurturing and inspiring relationship with those whom they expected to be their mentors and guides. The reality was more complex.

Students' poetry not infrequently noted their shock and disbelief when the faculty physicians who were supposedly their role models treated them disrespectfully and contemptuously. Bobby Rostami uses a mordant humor to recount a dialogue between a medical student and an obstetric-gynecological surgeon, in which the surgeon's "cutting" questions and comments are not stated but are easily inferred from the medical student's self-denigrating responses. Behind the poem's wit lies obvious pain and humiliation. The surgeon taunts the student, calls him stupid and a "pussy," advises him to drop out of medical school, and tells him to drop dead. He also expresses loathing toward his patients and blames them for their diseases. The poem represents a deeply troubling failure of role modeling in its portrayal of a physician-teacher who is the antithesis of a healer and protector.

In this poem, the surgical patient is all but invisible as the student highlights his own humiliation at the hands of his physician-teacher, although both the student and the patient are victims of the surgeon's contempt and hostility. The poem's use of irony and sarcasm allows the student to give voice to his rage and disillusionment. In this sense, writing the poem becomes a vehicle for reducing the student's sense of vulnerability and protesting against the hierarchical power structure of medicine, which has the potential to victimize both patient and student.

More optimistically, Dennis Chang writes about an encounter with an HIV-positive patient with hepatitis C and liver cirrhosis who is throwing up blood. An intern is attempting to place a central line. The patient is simultaneously in denial and frightened. The student mediates between the intern and the patient, empathizing with the fear of both and providing the patient with human contact. Specifically, the student offers a part of himself (his hand) in exchange for the patient not moving during the painful procedure. As the patient feels pain, he squeezes the student's hand so tightly that the student, too, is in agony. Student and patient suffer together. But the desired outcome is achieved: The patient does not move, and the procedure is successfully accomplished. The student feels useful and effective. With happy irony, he cements the newly formed relationship by again offering his hand-only this time it is his other, non-damaged one. In this case, the student realizes he had an important, although undefined, role to play in this relational triangle.

Chang's poem adopts a narrative approach that helps define a valuable role for the medical student during the course of a painful procedure. By grasping the patient's hand (a highly symbolic part of the human body), the student is able to connect both literally and figuratively while mediating the anxieties of both the intern and the patient. The poem perceives the vulnerabilities of both intern and patient and identifies the medical student as the one best situated to rehumanize the encounter.


In these poems, we see medical students reflecting on their relationships with patients, patients' families, attendings, and residents. They adopted a mixture of voices to explore different professional relational systems. Perhaps most important, these poems gave expression and legitimacy to the students' own voice (Henderson, 2002). It has been noted how easily the rigidly defined professional identity to which medical students are socialized can constrict other aspects of the self (Kaiser, 2002). These poems legitimated the subjectivity of the students' observations and imagination (McLellan, 1996; Spatz & Welch, 2000), regardless of idiosyncrasy or variance from more prevalent social norms. As we have seen in these poetic examples, once students connected with their own voice, they were more likely to seek out the voices of patients and family members that might have been suppressed or marginalized in the healthcare system. It is interesting that, often within the scope of a single poem, we can detect fluidity and evolution in voice. For example, in the poem seeking to locate the humanity of the patient from the cold pages of the medical chart (Doo's poem, "Metamorphosis"), the patient becomes embodied and three-dimensional through the poetic dialogue created. Another poem, exploring a meaningful and mediating role for the medical student in the student-attending-patient triangle, proceeds from a voice of inadequacy and uncertainty to one of competence and solidarity (Chang's "My Hand").

The poems of these students often focused on mundane details that clinical experience and scientific research might regard as inconsequential. In doing so, they became a way of supplementing standard "medical telling" (Downie, 2002), allowing the students to concentrate on those elements of an encounter that might have mattered to them or to patients and families, if not to their attending. Because in poetry students are not required to state events "correctly" or to distinguish in the approved manner what is relevant and what is tangential, particulars of the relationships that students experience that are normally discarded as irrelevant may be retrieved, contemplated, and savored in verse. It is through "inconsequential" details carefully observed (the influence of teen magazines, the daughter's image of McDonald's as being under the control of Satan) that we learn about student, mother, and daughter in the poem about the student-family relationship organized around an eating disorder (Kalpakian's "Dueling Chief Complaints"). Similarly, the concreteness of details in the poem depicting an anti-role-model surgeon ("bloody scalpel," "cauterized flesh," the offensive term pussy) serves to underline the brutality of the attending (Rastami's "A 'Transcript' of My Conversations With Ob-Gyn Surgeons").

Poetry "helps lure students into perspectives other than the biophysical mode ... and helps students to see beneath the surface of things" (Spatz & Welch, 2000, p. 142). In their writing, these students were able to adopt an introspective, questioning attitude toward their own experience as well as toward conventional professional and organizational behaviors (Brookfield, 1993). For example, the poem dealing with a student's hostility toward patients (Chao's "Don't Come to Me for Help") allowed the author to express the "unacceptable" position, perhaps internalized from messages within the informal curriculum (Branch et al., 2001), of hostility and resentment toward patients. By examining alternative or complementary perspectives with empathic fellow feeling rather than scientific detachment, the poems also enabled students to "rehear" what patients or family members were saying. For instance, the poem reflecting on the conflicting voices of parent and healthcare workers (Shin's "A Mother's Will") literally builds opposing professional and maternal perspectives in its alternating lines but treats both respectfully.

As we have seen, these poems frequently made use of metaphors to express vital experiences succinctly yet compellingly (Bolton, 2001). Such images appeared to allow students to enter their clinical experience from unexpected vantage points, gaining new insights and understanding in the process. For example, in the poem about the crippled VA patient (Bahadori's "Mr. C"), transformation of the patient's amputated feet into a metaphor of courage and hope also resulted in a more positive reconceptualization of Mr. C. Similarly, the metaphor of flight toward the end of the poem about rehumanizing and reconnecting with the patient (Doo's "Metamorphosis") creates a powerful image of a shared journey.

Each of the poems cited was intended to evoke and invoke particular emotional states. At some point in the medical education experience, the professional language and knowledge that students have struggled so hard to master fail to satisfy (Stein, 1996). Poetry locates the author directly within emotional experience by removing the safety net of scientific discourse (Campo, 2003). The poems included here represent a range of emotions: admiration, affection, rage, humiliation, helplessness, joy, and hope. Rather than attempting to ignore or set aside emotional reactions as unprofessional (Smith & Stein, 1987), writing a poem gives students a chance to examine the emotion fully, experiment with different ways of expressing it, and explore its varied potential meanings.

Poetry has a long tradition of being perceived as having "the power to heal" (Coulehan, 1991). It is speculated, and some evidence supports, that poetry may be helpful in healing because of the incantation of rhythm and the actual act of crafting the poetry itself (Campo, 2003; Philipp & Robertson, 1996). Gropper (1998), reviewing the poetry of experienced physicians, wrote, "The depth of pain that physicians must witness ... is evident in these poems.... These physicians are, in some sense, trying to complete their work of healing" (p. 759).

Writing poetry often appeared to be an act of self-healing for these student physicians as well. One important way mentioned in many of the debriefing sessions that poetry seemed helpful to its authors was through the sense of empowerment it provided them. When students contemplated their professional relationships with patients, families, and teachers, they often felt helpless and frustrated. Writing a poem sometimes suggested ways of improving the situation or simply raising one's voice in an act of "witnessing" (Frank, 1995). Even when the poem itself did not express resolution, the students anecdotally reported feeling less traumatized and more whole.


Studying medical student poetry is a legitimate method for learning more about how students attempt to make sense of the different relational systems in which they participate during their educational years. In general, poems that focused on patients tended to express empathy and solidarity, although they were also used to conceptualize the patient as an undeserving and dangerous "other." The experiences and needs of families were less easy for students to penetrate, but student writing showed empathy for the family perspective. What engendered most disillusionment were the examples set by attendings and residents. Although at times students identified a redemptive role for themselves, often these poems articulated disillusionment, disappointment, and even betrayal. In sum, poems are a method by which medical students can make emotional sense out of their relational experiences in medical school--and, by extension, are a potentially rich source of data through which medical educators can better understand their students.


Student Poems
Mr. C.

   Mr. C. weighed 80 pounds, measured 3 feet tall
   all in all
   After having bilateral BKA's
   there wasn't much left of him ... or ...
   was there?
   Every morning I would see him
   cruising the halls of the VA
   in his motorized electric wheelchair
   cap set at a rakish angle on his head
   eyes twinkling with humor and delight
   Mr. C. the VA resident social butterfly
   There wasn't much left of him physically
   but boy was his presence
   I'll never forget his boyish smile,
   especially given his adverse circumstances ...
   One foot straddling life, the other death

--Maryam Bahadori, MD
My Hand

   "I've never been sick a day in my life."
   I think, you have HIV.
   "I don't know why this is happening to me."
   I think, you have Hep C liver cirrhosis.
   "I just threw up 5 cups of blood!"
   I think, with surprise, that's no big deal.
   The team's seen worse ... and things are under control.

   He says, "Tell me he's old enough to do this."
   I tell him, "He's well-trained. He's good enough."
   I think, my intern is only 27.
   He says, "Tell me it won't hurt."
   I tell him, "It's just a central line.
   We need to give you blood and fluids."
   I think, my intern must be sweating bullets.

   He says, "I'm scared."
   I tell him, "Don't move. You can squeeze my hand,
   but just don't move."
   I think, He can't move. Not when my intern
   does the stick, he can't move.

   I read my intern's eyes. He's scared too.
   But we know what we have to do.

   He grabs my left hand. I smile.
   Internally, I gasp. It's crushing.
   "Anesthetic going in," R2 says. I say comforting words.
   Inside, I grimace in pain. He's breaking my hand.
   "Don't move," R2 says. "Putting in line."
   The patient grits his teeth and moans.
   I can no longer feel my hand. But I smile and I tell the patient
   "Good job."
   Because he didn't move.
   He didn't move.
   He didn't move.

   It's over and he thanks me.
   I smile. I feel like a member of the team.
   I think, maybe medical students are good for something
   after all!
   As I leave, I give him my hand with a smile.
   My right hand.

--Dennis Chang, MD
Don't Come to Me for Help

   Diabetes, COPD, CHF, renal failure
   What awaits me behind the next door?
   What chronic disease is next in line to control, but not cure?

   Another non-compliant patient?
   Another patient who doesn't care?
   Or is it another who cares too much
   And thinks he/she knows more than me?

   Frustration builds and turns to ambivalence
   What do I care?
   Why should I care if the patient doesn't?
   All I can do is give my professional opinion
   But why do they keep coming back
   SSDD--same shit, different day?

   No change in symptoms, gee I wonder why
   Maybe if you listened and tried you'd feel better

   I/We can only do so much
   Patients need to learn to care for themselves
   If they can't
   Don't come to me for help

--Micheal Chao, MD

   First contact-Via
      chart, presentation
      A refined conglomeration of
      Vitals and diagnoses
      And physical findings
      Described in the jargon of medicine,
      The abbreviations
      Nigh impenetrable to those uninitiated
   Humanity cloaked
      By a diagnosis
      With each word spoken in
      Your own voice, each exchanged whispered
      And exclaimed, with each disclosure
      A cocoon erupts.
      Texture disrupts sterile pages
   Intervene! Help me to look beyond
      This chart with your life
      Deny me the temptation to
      Interpret you as a process, reduce you
      To a treatment plan
      Let me in on the irrelevant, the
      Maybe-not-so insubstantial
   It is no mere conjurer's trick
      To uplift print into humanity
      Construct a being out of labs
      Perhaps it is enough that
      You are my patient--the
      Discovery that I am as
      Human as you
   Perhaps it should not be
      My fate to walk this
      Future alone, in hand with
      Just another case
      Study or learning opportunity,
      Just another entry in
      Some log
   Perhaps it is all that ever matters
      Let us take flight!-And
      for even a visit,
      Maybe a lifetime
   Face this world, foreboding, and
      Hopeful, you and me,

--Michael Doo, MD
Dueling Chief Complaints

   Some of my patients tell me they want to grow up to be firemen.
   Some want to be doctors.
   Some want to grow up to become that luscious purple dinosaur.
   Not Angela.
   Angela wants to grow up to look like the girls on the cover of
   Seventeen magazine.
   Her mother tells me her chief complaint is that her daughter
   looks too much like
   those girls already.
   Angela's chief complaint is that she does not look enough like them.
   I take her nutritional history.
   Her mother insists that she doesn't eat enough.
   Angela declares that she eats too much.
   Her mother wants to take her to McDonald's.
   Angela thinks McDonald's is run by Satan.
   She laughs gleefully when she learns that 99% of girls her age weigh
   more than she does.
   While Angela continues with her obsession to weigh less than air,
   I continue with my obsession--searching for zebras.
   I pray that I can find some rare malabsorption disorder that could
   her cachectic state but I can't.
   Angela is a beautiful, smart young girl, who is unraveling.
   ... caught in the spider web of Madison Avenue's images.
   ... yearning to accomplish the unaccomplishable goal of perfection.
   She's like a piece of fine china, teetering at the edge of a table,
   ready to fall.
   I wish I could put her back together again
   ... with a medicine or a band-aid or, God help me,
   with that stupid purple dinosaur.
   But I can't.
   I feel incredibly powerless.

--Mary Alice Kalpakian, MD
A "Transcript" of My Conversations with Ob-Gyn Surgeons

   Yes sir doctor, I am a third year. Bobby Rostami, sir.
   Thank you for allowing me to watch this procedure, doctor.
   Yes sir I did scrub for 5 minutes.
   Yes sir I tried to learn the names of the instruments.
   Well I don't know, sir, I guess I didn't learn them well enough.
   Yes sir I am stupid.
   Thank you for telling me how to do it correctly.
   Yes sir, I agree, I hate patients too.
   Yes sir, it is their fault for getting the cancer, sir.
   Yes sir, I also deserve to get a tumor sir.
   Well sir, I don't know why the standard approach for uterine
   cancer is like this.
   You're right, sir, this is further testament to the fact that
   medical students are getting
   stupider and stupider as the years go by.
   Yes sir, I wish I were dead too, sir.
   Yes, thank you for sticking that bloody scalpel in my face sir.
   I now know how
   to use one.
   Well sir I'm not used to waking up at 3:20 a.m. and standing
   on my feet for
   9 straight hours.
   Yes sir, it does show what kind of a pussy I am.
   Yes sir, you're right. I should pray for my own death.
   Thank you for praying for it as well sir.
   Well yes sir, I do enjoy the sweet savory smell of cauterized flesh.
   Yes sir, you can cauterize my intact flesh. Mmmm that smells great.
   Yes sir, I agree. I should drop out of reed school and become a
   shoe salesman.
   Thank you, sir, for allowing me to watch this procedure, sir.
   Ha ha ha ... thanks for tripping me on the way out of the operating
   room, sir.

--Bobby Rostami, MSIV
A Mother's Will

   I almost lost you
   a placenta misplaced
   You will bleed and lose
   Flat on my back,
   you kicked inside me
   He will die in your belly
   For eight months, I will
   keep stirring with life
   Congratulations, a boy
   All that I had hoped
   grow steady and sure
   Too small, too slow
   Already babbling
   I understand you.
   Too little, too late
   My sweet little prince
   looks just like papa
   May be a syndrome
   Listen to me
   nothing is wrong
   There are specialists to help
   Love and dedication
   we did it before
   He needs more than affection
   They said it couldn't be
   I knew it could, I would
   I will
   Not lose

--Susie Shin, MD


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Johanna Shapiro, PhD, Department of Family/Medicine, College of Medicine, University of California, hwine; Howard Stein, PhD, Department of Family and Preventive Medicine, Health Sciences Center, University of Oklahoma.

Student contributors were Maryam Bahadori, MD, Micheal Chao, MD, Dennis Chang, MD, Michael Doo, MD, Mary Alice Kalpakian, MD, Bobby Rostami, MSIV, and Susie Shin, MD.

Correspondence concerning this article should be addressed to Johanna Shapiro, PhD, Department of Family Medicine, College of Medicine, University of California, Irvine, 101 City Drive South, Route 81, Building 200, Suite 512, Orange, CA 92868. E-mail:
Table 1

Thematic Summary of Medical Student Poetry
Written Over a 4-Year Period in Fulfillment of
a Creative Projects Requirement for the
Internal Medicine and Pediatric Third-Year

Relationship and theme                       of poems

  Patient as teacher                             18
  Solidarity with patient                        16
  Patient as enemy                                9
  Cultural differences                            7
  Failing patients                                5
  Connection/detachment with
    patients                                      5
  Staff/parent voices                            10
  Family dynamics                                 9
  Family/doctor/student                           9
  Neglectful parents                              7
  Attending as anti-role-model                   14
  Student as systems mediator                    12
  Attending as role model                         6
  Other (a)                                      44

(a) Topics unrelated to professional relational
systems included death and dying, spirituality,
socialization, stress, the patient's perspective
on disease, and meditations on the nature
of illness.
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Author:Shapiro, Johanna; Stein, Howard
Publication:Families, Systems & Health
Geographic Code:1USA
Date:Sep 22, 2005
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