Louise Younie, Clinical Senior Lecturer, Barts and The London School of Medicine and Dentistry

Published in JHH18.1 – Flourishing in Medical Education

Ever since qualifying as a GP I have been seeking ways to develop understanding of ourselves and our practices as students and clinicians. Creative enquiry, that is reflective engagement on our lived experiences through the arts, has been central to this 15-year journey into ‘practitioner development’ and the intersubjectivity of practice. I have discovered that through the languages of the arts people find voice and express what might be difficult to articulate, potentially allowing for deeper meaning[1]making, engaging with shadow work, exploring ‘what is’, rather than an idealised idea of what should be. Witnessing this sharing of lived experience and how this builds connection, relationship and solidarity through creative enquiry has sparked my interest in human flourishing and broadened ideas around student or clinician wellbeing. www.creativeenquiry.qmul.ac.uk @LouiseYounie

We were discussing how it is almost taboo to show emotion about [witnessing patients being told they had breast cancer], not only on the wards but also when chatting afterwards to other students. There is an unwritten rule that you have to prove…. that you can cope with hearing/having to give bad news and be absolutely fine with it. That’s the mark of a good doctor – leaving it all in the hospital. I would say that the creative arts course countered that beautifully…’(Medical student, 2009)

(Younie, 2011)

The doctor’s inner life has been described as having ‘ominous heaps of unarticulated experience accumulating inside dark warehouses made of thin walls, with doors that do not reliably close’ (Scannell, 2002). Scannell invites entry to this warehouse ‘with a fistful of words [using] them like keys, finding which ones fit to open you to greater expanses of your personal experience’. Medical students I have worked with in the field of creative enquiry (that is, reflecting on lived experience through the medium of any of the arts – creative writing, photography, sculpture, dance, music etc) testify to this potential of the arts to bring them into connection with their own inner lives:

‘…I believe that I learnt more about myself in the past two weeks than I have in my 21 years. I have been able to open up, when I have always kept my emotions and thoughts to myself… (Medical student, 2019)

(Younie, 2019)

The creative enquiry experience also builds relationship and connection across members on a student selected component.

It felt like quite a privilege to listen to people opening up and describing things that really touch and matter to them.’(Medical Student, 2005)

(Younie, 2006)

Over many years of bringing creative enquiry into medical education I have witnessed how reflective engagement with the arts can facilitate connection, transformation, learning and growth thereby contributing to what Aristotle has described as eudaimonia (Huta, 2015). Eudaimonia, originally often translated as happiness, but more recently conceptualised as flourishing, relates not so much to the pleasure and enjoyment of hedonia as to meaningful engagement and personal growth.

Creative enquiry offers:

Multilingual engagement

Flow and silence

Improvisation

Ways in which the arts can transform the learning space

The creative enquiry process of ‘making…artistic expressions…as a primary way of understanding and examining experience’ (McNiff, 2008) invites learning, growth and connection in ways that might be hard to reach with other methods. These include engaging with the different linguistic and communicative properties of the arts, entering into flow, silence and an improvisational approach, each of which I will explain below.

Language and the arts

Engagement with the arts (photography, music, dance etc) juxtaposed with verbal or written reflective prose introduces multilingual processing of experience.

Each of the arts are different sign systems offering different possibilities and limitations in our cognitive/ emotional work, for example, movement in time to the dancer; words, rhythm and silence to the poet. The arts also allow space for emotional expression, uncertainty and ambiguity inviting interpretation.

‘I felt it was a better way of showing how I felt about the patient…[and] the difficulties he is facing.

(Student feedback, year 1 GP attachment, 2009)

[Creative enquiry] allows me to express more… It also allows others to interpret it in their own opinion,not just my own.(Medical student, 2009)

(Younie, 2011)

Flow and silence

In a group setting, as students engage with arts based materials or processes (writing, collage etc) the room often descends into an active and shared silence, described as ‘flow’ – a state of absorbed concentration (Csikszentmihalyi, 1990), where thoughts and concerns evaporate and for the moment all energy goes into the making.

The silence in and of itself can be therapeutic.

One thing that really struck me about the process was how calming it was. There was no talking in the room for 20 minutes because of how busy everyone was making their own art, and all you could hear was the rustling of materials or the gentle sound of pencil against paper. I felt like I was in a safe space. (Medical student, 2019)

(Younie, 2019)

Since I have come to university… I never… have time or space for myself to just truly slow down… and reflect… It’s… like a light that is constantly turned on. This whole week actually helped calm me down…The periods of silence throughout the week are when I think I was able to sort out a lot of feelings and things I was experience in my personal life…(Medical student, 2019)

(Younie, 2006)

Improvisation

I encourage medical students to focus on the process of creating rather than the product of their creation, because concern with the outcome rather than playful or improvisational engagement stifles the learning and exploration. It means being responsive rather than dictatorial to what the materials offer, so that the work itself secures its own voice and helps set the direction (Eisner, 2002). Hepworth (1970) describes this responsiveness to materials. She uses her left hand as her listening hand to explore the stone upon which her right hand hammers and sculpts. A medical student uses poetic form to describe the potential for openness and responsiveness in creative enquiry, listening for what might emerge from the unformulated and unspoken dimensions within.

I step into the room, emotions and baggage boxed up inside. Worries and preconceptions rising. In front of me lies a table, materials laid out, a blank canvas.

I choose the colours, I choose the medium, my emotions determine my first move. This is between me and the paper only.

Pencil touches paper and the emotions begin.

Movements and shapes flow through my hand. I catch an emotion and draw.

Searching through the cavern of feelings, discovering what has happened. Thoughts previously left unstirred are brought to the surface. A reflection is created of what has been stirring.

My hands swirl and dance around the page, untangling different threads, treading on untouched.

Freedom to express, freedom to be.

The colours fall onto the page, tumbling down, intertwining.

This is me.

What was hidden is being brought out, showing itself, an image, an artwork.

(Naomi Smart, medical student, 2017)

Connection, learning, sharing through the arts

Through metaphor and symbolic representation, voice may be given to emotional, difficult-to-express dimensions of practice, often leading to connection and the building of solidarity. Students are surprised, for example, to find that they are not the only one feeling at sea with the huge emotional and intellectual demands.

I didn’t expect to hear that other students felt out of their depth or like other people were more talented or bright than them so it was nice to discover that I am not the only one.’

(Medical student, 2018)

One student described herself as the small black fish in the bottom left-hand corner, surrounded by brightly coloured and vibrant other fish (medical students). Another student said she felt like a grape among chess pieces honed and ready for battle, but through the creative enquiry course came to think of herself more as a ‘grape among grapes’. Creative enquiry as a process allowed another student to face unspoken, unarticulated concerns she had been carrying about medicine. She writes, ‘I realised that true wellbeing is facing what we are struggling with and not avoiding it’. This kind of flourishing is about connecting in a real way with ‘what is’, rather than instructions to try to do better (eat well, sleep well, do hobbies). Another student writes:

…I have never been someone that opens up easily, even to close family and friends, and being able to share my ideas in the form of drawings, poetry or prose in a comfortable and safe environment had more of an effect on me than I had imagined it would. I felt relief at sharing some of the feelings and thoughts that had weighed on me…

(First year medical student, 2018)

Facilitation of creative enquiry

Engagement in the process of improvisational working with different arts based materials opens up a learning space of exploration, expression and emotional engagement.

With painting, the freedom to explore, make mistakes and express feeling and opinion in a safe environment feels amazing… So to be given permission to express myself and think beyond the immediate and into my imagination was another nourishing experience… I feel medicine has the power to shrink your world if you allow it, and this is a bad thing for both you and the quality of the medicine you can practice.’

(Student, Creative Arts SSC)

In the small group setting, this is supported by facilitating a learning opportunity where psychological safety has been established (Edmondson et al, 2016), with invitation to attend to one’s own personal boundaries and how much to share, as well as collective creation of ground rules, eg ‘confidentiality’ and ‘all ideas valid’. There is artistry also for the facilitator in creating this kind of transformational space (where new ideas, beliefs, perspectives may emerge) which Seeley has described as being the ‘artist of the invisible’ (Seeley, 2011). Sharing is also supported by the facilitator taking a ‘vulnerable lead[1]ership’ approach (Younie, 2016) – being present, being real, sharing, for example, some of the real-life challenges we face in clinical practice. This is appreciated by students and mitigates for a process that might otherwise cause anxiety and feel exposing, superficial or alienating.

I really enjoyed how open and honest nearly every facilitator was in these sessions. As a medical student, I often feel like I’m not important enough to already know details about people’s lives, especially teachers. It is too often that younger people are put down because they seem to not have lived enough or know enough so I was very humbled by the honesty of everyone. I truly felt like we were equals and I think that is what makes a course more inviting, dynamic and influential. So, thank you to everyone that made that possible.’ (First year medical student, 2018)

(Younie, 2019)

Thank you to all the other facilitators of the creative arts course and to the students who have engaged in creative enquiry some of whom you will encounter in this volume.

References

• Csikszentmihalyi M (1990) Flow: The psychology of optimal experience. Harper and Row.
• Edmondson A, Higgins M, Singer S, Weiner J (2016) Understanding psychological safety in health care and education Organizations: A comparative perspective. Research in Human Development [online] 13(1) 65–83.
• Eisner E (2002) The arts and the creation of mind. RR Donnelley & Sons
• Hepworth Bm (1970) A pictorial autobiography. Tate Publishing
• Huta V (2015) The complementary roles of Eudaimonia and Hedonia and how they can be pursued in practice. In Joseph S (ed) Positive psychology in prac[1]tice: Promoting human flourishing in work, health, education, and everyday life. John Wiley & Sons.
• McNiff S (2008) Arts-based research. In Knowles JG, Cole AL (eds) Handbook of the arts in qualitative research. Sage.
• Scannell K (2002) Writing for our lives: physician narratives and medical practice. Ann Intern Med, 137(9) 779–81.
• Seeley C (2011) Uncharted territory: Imagining a stronger relationship between the arts and action research. Action Research, 9(1) 83–99.
• Younie L (2019) Flourishing through Creative Enquiry. Queen Mary University of London. www.creativeenquiry.qmul.ac.uk/?page_id=213 (accessed 22 March 2021).
• Younie L (2016) Vulnerable leadership. London J Prim Care, 8(3) 37–8.
• Younie L (2011) a reflexive journey through arts-based inquiry in medical educa[1] EdD Dissertation, University of Bristol.
• Younie L (2006) A qualitative study of the contribution medical humanities can bring to medical education. MSc dissertation, University of Bristol.