Louise Younie, Clinical Senior Lecturer, Barts and The London, QMUL

Published in JHH 18.2-Frontiers of self-care

To this end I have had the privilege of engaging medical students in creative enquiry (exploring lived experience through the arts) for many years and through a variety of approaches (Younie, 2014). The engine of creative enquiry innovation in the medical curriculum is the creative arts for health student selected component which I set up in 2004 at the University of Bristol and continue to run at Barts and The London, QMUL. Working with a small group of self-selecting students allows for piloting approaches and co-creative exploration in the field. Students opt for a two-week course which is cofacilitated by arts therapists, arts for health consultants, clinicians and patient artists. Each three-hour workshop has a similar format where students:

• witness patient creative enquiry work
• engage in a variety of arts-based processes (eg photography, collage, creative writing, sculpture)
• share their creations
• engage in group-based dialogue on patient and their own lived experiences in medicine.

This year through Covid-19 pandemic restrictions the courses have been facilitated virtually for the first time. There have been some benefits – patient artists can facilitate without having to travel – as well as the losses of not being in the same room, not being able to lay out all the workshop materials to choose from, and missing our informal coffee breaks together. Despite the challenges in 2021 a group of 12 first-year students connected deeply during this course, which ended with our producing creative enquiry art and text on lived experience (three of which are published in this edition).

‘I vividly recall being astounded at the support and warmth with which my peers approached my contribution, and this gave me a feeling of solidarity and acceptance that I had not yet felt during my experience of online medical school, and which boosted my confidence to contribute further in later discussion…’
(Medical student, 2021)

Students noted the importance of the learning environment as well as the creative enquiry process, in creating this learning space.

‘The SSC provided a unique environment, bound by core values of confidentiality, non-judgement and the concept of “no wrong answer”. I truly valued this and found it liberating to speak my ideas freely, and hear colleagues build on those ideas.’
(Medical student, 2021)

‘Creative exploration is a tool in this process. In one sense, we can further understand our own reactions, thoughts and emotions, and in another sense creative work can provide an insight into what others experience.’
(Medical student, 2021)

It’s been a year of pandemic, of isolation, online learning and pressures on doctors, patients and the whole healthcare system. Humanising our approaches to patients as well as considering the wellbeing and humanity of medical students are both paramount and go hand-inhand. As a medical educator, I seek to move the conversation beyond individual strength or capacity to ‘bounce back’ (the usual framing of resilience), towards a more humane, interconnected and ecological take on wellbeing. I describe this as flourishing (Younie, 2020). Flourishing is rarely mentioned in the medical education literature, but by drawing on philosophy, psychology, and exploring the concept with medical students and in symposia, presentations and publications (Younie, 2020. 2021) the value and character of flourishing in medicine is emerging.

To speak of flourishing metaphorically connects our inner lives with trees, flowers, gardens and their seasonal ebb and flow of loss and renewal, death and growth. To flourish, is not necessarily to be happy and have it all perfectly sorted out (hedonia), so much as it is about connection with our values, with purpose and meaning (eudaimonia) (Younie, 2020). In considering what it might mean to flourish, students are invited to move away from perfectionism, to embrace and share ‘what is’ rather than what ‘should be’. I call this ‘shadow work’: engaging with parts of ourselves and our lives that we might prefer to ignore and forget. Such hard-to-articulate work can be facilitated through the metaphorical and symbolic approaches of creative enquiry, which enables images, ideas and memories to emerge from the fringes of our consciousness. Symbolic engagement with lived experience through drawing, painting, creative writing etc is followed by reflection, where students may share vulnerability, build relationship, trust, connection and a sense of community.

In the three student texts that follow – two images and a song – students explore flourishing themes. They depict the pressures medical students are experiencing in the pandemic, the personal and professional expectations faced, and the facades adopted to show the world they can cope. But they also recognise the importance of selfcare, of listening to our hearts and the possibility of showing kindness and compassion to ourselves.

‘Shadow work’ is described across the student texts, for example, engaging with the ‘pressure to hold yourself up to certain standards’ (Guto), the ‘facades…controlled [by] even our own expectations’ (Alia), and ‘my feelings of uncertainty and weariness’ (Yunrui). There is liberation in being able to share ‘what is’ without having to try harder and do better, as helpful as advice on eating and sleeping well might be in themselves. When group members were asked to voice something they were happy about and something that concerned them, there was relief all round in sharing formerly unspoken struggles with the exam pressure they all were facing, and to find themselves not alone.

Yunrui describes flourishing as a new ‘mindset to view the world’, moving away from the pressure to be ‘resilient’, ‘not show my weakness’, ‘put up a strong front’. Flourishing instead, she writes, ‘has taught me to embrace who I am’. She later concludes, ‘through understanding… we can come to peace with our worries and flaws’.

Alia describes this acceptance of self and moving away from needing to be perfect:

‘It is okay to not be the best, and it is okay to not
live up to every expectation. It is okay to take
things slow and take a breather. It is okay to make
mistakes then learn from them, and it is okay to
put your mental health first.’

Self-care and compassion also emerge as important themes alongside the self-acceptance Alia describes. Guto presents us with the ‘Patient Care 330ml’ and ‘Self Care 0.5%’ beer bottle, illustrating how little self-care we often give ourselves, and tells of the impact this might have on patient care, because ‘low levels of self-care can impact on your ability to care for others’. Alia turns this around, proposing that we need to be compassionate with ourselves, not only to offer care and compassion to others, but also in order to be able to receive compassion from others. Her kind hand with its messy ball of string symbolising self-compassion is a call to stop being shackled to unrealistic expectations. Yunrui goes on to remind us of the beauty of nature – ‘rivers, blue skies and blooming flowers’, and invites us to hit the ‘pause button’, to listen to our hearts and to trust where our hearts lead.

Hear,
the river’s calling
For you to look inside not down
And you will see how much
there’s
In the power of your heart

• Schön DA (1983) The reflective practitioner. How professionals think in action. BasicBooks.
• Younie L (2021) Flourishing through creative enquiry: humanising the medical experience. Journal of Holistic Healthcare,18(1) 3–5.
• Younie L (2020) When I say flourishing in medical education… Journal of Holistic Healthcare,17(3) 44–46.
• Younie L (2014) Arts-based inquiry and a clinician educator’s journey of discovery. In: CLMcLean (ed) Creative arts in humane medicine. Brush Education Inc.