Synapse, Special Announcement: Spring 2007

Quantifying the Power and Pleasure of Ideas: A New Approach to Evaluating the Literature & Medicine Program
by Brita Zitin ::: bio

Literature & Medicine: Humanities at the Heart of Health Care® is a reading and discussion program for medical professionals that, as one participant writes, “renews the heart and soul of health care.” Program participants work in all aspects of patient care, and include nurses, physicians, support and allied staff, administrators, clergy, social workers, and therapists in hospital, home health, hospice and public health settings. The opportunity for these professionals to talk about their work with colleagues is rare, and the effects of bringing them together to reflect on lived experience through the lens of literature are often profound.

After reading Kafka’s The Metamorphosis, I worked with a patient who had cancer and was also depressed. I mentioned I had read it and the patient [had] read it, too. Through the book, I found a new way to understand his treatment and diagnoses.

I held the hand of a dying patient, a person I had known for 18 years. I told her that I loved her and held her hand as she died. I have usually been more detached, but gentle, and let others sit with the patient, so I could continue with my busy work. But I hesitated, sat at the bedside, and decided NOT to leave. To BE with her.

Oddly enough, calling some doctors by their first names has been a big behavioral change for me!

In two instances, my relationships with other health care professionals improved because we shared the experience of communicating about our reading. In one case, we did not agree and, in fact, for a few moments were in rather vehement opposition, but having that experience in a safe arena improved our working relationship.

I have used our reading or Lit & Med group interactions on several occasions to help employees, managers, and medical staff to look at a work situation or a specific patient/family issue. Literature & Medicine is a wonderful program that helps build the empathy and understanding of all patients and staff.

Some of the materials we read looked at cross-cultural experiences. When an African American resident on my team asked a question about our “standard way of doing things,” I was able to go beyond “this is just the way it is” to think about what that “way” looked like to someone from a background different from my own—something I might not have even thought about previously.

Comments from 2006 Participant Evaluations

Since 1997, when it was created by the Maine Humanities Council, Literature & Medicine has been a success by a variety of measures. It started with a single pilot group at Eastern Maine Medical Center in Bangor, Maine, but by this year, Literature & Medicine groups will have met in over 90 different hospitals and other health care settings in 19 states, from Florida to Montana and Maine to Hawai’i. The program’s expansion has been made possible by the close partnership of participating state humanities councils and support from the National Endowment for the Humanities. The program was named a Patient Quality Initiative by the Maine Hospital Association in 2002. In 2003, it was awarded the Helen & Martin Schwartz Prize for Excellence in Public Programming by the Federation of State Humanities Councils. Press coverage has ranged from local newspapers to national publications like Academic Medicine: Journal of the Association of American Medical Colleges and the Christian Science Monitor.

In spite of all this acclaim, there remained—until recently—a lack of systematic evidence that Literature & Medicine accomplished what it said it did. Most hospital administrators are compelled to be number-crunchers, even if they are humanists at heart. They judge professional development programs on the standards they meet and results they deliver. Unfortunately, reading and discussion programs are notoriously resistant to these types of measures. Their transformative effect occurs incrementally, and participants often struggle to describe it. There are no control groups, no placebos and very few objective indicators of success. How could participant feedback on Literature & Medicine—which was copious and consistently positive—be captured in a format that would appeal to quantitative minds?

To explore new methods of evaluation, the Council secured funding from the National Endowment for the Humanities and turned to Dr. Bruce Clary at the University of Southern Maine’s Muskie School of Public Service. Clary engaged Council staff in intensive reflection and conversation on the program’s goals and methods. They identified five basic goals for participants: increased empathy for patients, greater cultural awareness, improved interpersonal skills, better communication skills and greater job satisfaction. Then they worked backwards to identify particular components of the program, linking the outcomes to the stated goals. This structure comes from the Kellogg Foundation logic model: “a systematic and visual way to present an understanding of the relationships among the resources you have to operate your program, the activities you plan, and the changes or results you hope to achieve.”¹ Working with the logic model, Clary designed an online questionnaire and sent it to all Literature & Medicine participants for the year 2006. Responses came from 278 participants in eight states. Clary also collected qualitative data from focus groups he conducted at four program sites.

Clary’s survey measured change in individual participant attitudes in five areas, or “domains,” linked to the five goals, using a standardized four-point Likert scale—the lower the number, the greater the change. Results for every domain revealed an impact from the program (Table 1). The impact was most significant in the domains of empathy and cultural awareness. As Clary wrote, “These domains are complex and not easily taught within organizational settings. […] The ability of the Literature & Medicine program to have an impact [on them] is a distinct contribution to the health care workplace.” Literature & Medicine not only prompted change in these domains, but also gave participants language to describe it: in Clary’s focus groups, participants talked about different perspectives, more compassion, holistic behavior, deeper relationships, greater honesty, understanding sub-cultures and transcending everyday issues with patients.

The survey also invited open-ended comments on outcomes in the workplace environment. As with the scales measuring individual outcomes, empathy was the most frequently cited benefit of the program. “I have learned to be more honest with patients and to take the time to see where they are coming from emotionally, spiritually, and mentally,” wrote one participant. Other comments focused on improved relationships with colleagues. Participants found that the program opened doors to networking and collaborative problem-solving: “Participating with colleagues on a non-clinical level in a discussion of patient, family, and professional issues inspired a new appreciation of our work, our goals, and each other.”

Finally, the survey asked participants to describe a specific event to illustrate the impact of Literature & Medicine. The goal of this question was to “ground” responses in terms of daily professional life. The 128 resulting statements offered a close-up, personal view of the program’s impact (see sidebar for examples).

This kind of anecdotal evidence, combined with figures from the survey, can help hospital administrators determine how to direct their limited professional development resources. It also helps busy medical professionals decide how to spend their scarce free time. But the results of the evaluation won’t be used merely as selling points. Even while affirming that the goals of Literature & Medicine are being met, the data that Clary is gathering—in both numeric and narrative form—will help Council staff refine and improve the program. So, please be sure to complete an evaluation if you are a participant this year! Your responses do matter.

To learn more about the Council’s evaluation efforts, please contact Associate Director Victoria Bonebakker.

Dr. Bruce Clary will lead a workshop on evaluating Literature and Medicine programs at our conference in November.

For more information, please contact Lizz Sinclair, the Program Officer for Literature & Medicine at MHC.