Doctors as Makers.

Traditional skills and expertise are not enough to prepare future physicians for the complexity, instability, and uncertainty of clinical practice. Responding and making meaning from ill-defined or unusual problems calls for, even demands, creativity. In this article, the author suggests expanding the traditional role of doctor as science-using, evidence-based practitioner to include that of doctor as a "maker" (creator) and artist. Such a reimagining requires a shift in how we view medical knowledge and patients' stories, as well as a new appreciation for "not-knowing" as a generative, creative space in medicine. Creative thinking deserves a central place in the training of doctors, driven by a reconceptualization of the traditional educational model to include medical disciplines, humanities scholars, artists, and designers.

Playing in the "Gutter": Cultivating Creativity in Medical Education and Practice.

In comics, "gutters" are the empty spaces between panels that readers must navigate to weave disjointed visual sequences into coherent narratives. A gutter, however, is more than a blank space--it represents a creative zone for making connections and for constructing meaning from disparate ideas, values, and experiences. Over the course of medical training, learners encounter various "gutters" created by the disconnected subject blocks and learning experiences within the curriculum, the ambiguity and uncertainty of medical practice, and the conflicts and tensions within clinical encounters. Navigating these gutters requires not only medical knowledge and skills but also creativity, defined as the ability to make connections between disparate fragments to create meaningful, new configurations. To cultivate medical students' creative capacity, the authors developed the Integrated Clinical Arts (ICA) program, a required component of the first-year curriculum at the Warren Alpert Medical School of Brown University. ICA workshops are designed to place students in a metaphorical gutter, wherein they can practice making connections between medicine and arts-based disciplines. By playing in the gutter, students have opportunities to broaden their perspectives, gain new insights into both medical practice and themselves, and explore different ways of making meaning. Student feedback on the ICA program highlights an important role for creativity and the arts in medicine: to transform gutters from potential learning barriers into opportunities for discovery, self-reflection, and personal growth.

Objective Assessment and Thematic Categorization of Patient-audible Information in an Emergency Department.

OBJECTIVES: The objective was to assess and categorize the understandable components of patient-audible information (e.g., provider conversations) in emergency department (ED) care areas and to initiate a baseline ED soundscape assessment. METHODS: Investigators at an academic referral hospital accessed 21 deidentified transcripts of recordings made with binaural in-ear microphones in patient rooms (n = 10) and spaces adjacent to nurses' stations (n = 11), during ED staff sign-outs as part of an approved quality management process. Transcribed materials were classified by speaker (health care provider, patient/family/friend, or unknown). Using qualitative analysis software and predefined thematic categories, two investigators then independently coded each transcript by word, phrase, clause, and/or sentence for general content, patient information, and HIPAA-defined patient identifiers. Scheduled reviews were used to resolve any data coding discrepancies. RESULTS: Patient room recordings featured a median of 11 (interquartile range [IQR] = 2 to 33) understandable words per minute (wpm) over 16.2 (IQR = 15.1 to 18.4) minutes; nurses' station recordings featured 74 (IQR = 47 to 109) understandable wpm over 17.0 (IQR = 15.4 to 20.3) minutes. Transcript content from patient room recordings was categorized as follows: clinical, 44.8% (IQR = 17.7% to 62.2%); nonclinical, 0.0% (IQR = 0.0% to 0.0%); inappropriate (provider), 0.0% (IQR = 0.0% to 0.0%); and unknown, 6.0% (IQR = 1.7% to 58.2%). Transcript content from nurses' stations was categorized as follows: clinical, 86.0% (IQR = 68.7% to 94.7%); nonclinical, 1.2% (IQR = 0.0% to 19.5%); inappropriate (provider), 0.1% (IQR = 0.0% to 2.3%); and unknown, 1.3% (IQR = 0.0% to 7.1%). Limited patient information was audible on patient room recordings. Audible patient information at nurses' stations was coded as follows (median words per sign-out sample): general patient history, 116 (IQR = 19 to 206); social history, 12 (IQR = 4 to 19); physical examination, 39 (IQR = 19 to 56); imaging results, 0 (IQR = 0 to 21); laboratory results, 7 (IQR = 0 to 22); other results, 0 (IQR = 0 to 3); medical decision-making, 39 (IQR = 10 to 69); management (general), 118 (IQR = 79 to 235); pain management, 4 (IQR = 0 to 53); and disposition, 42 (IQR = 22 to 60). Medians of 0 (IQR = 0 to 0) and 3 (IQR = 1 to 4) patient name identifiers were audible on in-room and nurses' station sign-out recordings, respectively. CONCLUSIONS: Sound recordings in an ED setting captured audible and understandable provider discussions that included confidential, protected health information and discernible quantities of nonclinical content.

Informed consent and advance directives.

Contrary to popular belief, a patient's signature on a piece of paper does not constitute informed consent. This article describes the ethical framework of consent in the context of the larger process of informed decision making. The elements of informed consent are examined in practical terms. Common pitfalls are addressed, with strategies to help anticipate and resolve possible dilemmas. These important tools are integral to all levels of medical decision making, including those at the end of life.

Creative writing as a medical instrument.

Listening and responding to patients' stories for over 20 years as an emergency physician has strengthened my appreciation for the many ways that the skills and principles drawn from writing fiction double as necessary clinical skills. The best medicine doesn't work on the wrong story, and the stories patients tell sometimes feel like first drafts-vital and fragile works-in-progress. Increasingly complex health challenges compounded by social, financial, and psychological burdens make for stories that are difficult to articulate and comprehend. In this essay, I argue that healthcare providers need to think like creative writers and the skills and sensitivities necessary to story construction deserve a vital space in medical education. A thorough understanding of story anatomy and the imaginative flexibility to work stories into open spaces serve as antidotes to the reductive nature of clinical decision making and have implications as patient safety and risk management strategies. The examples that I have selected demonstrate how thinking like a creative writer functions at the bedside, providing tools for clinical excellence and empathy. This approach asks that we re-imagine the importance of story in clinical care: from a vehicle to a diagnosis to its place as a critical destination.