MOVING FROM PERFORMANCE TO TRANSFORMATION

American society has had a reckoning with issues of diversity, systematic racism, and inclusion over the last year. Medicine is no exception. The hierarchy and privilege embedded in healthcare mirror society and the status associated with various positions in the social ladder of medicine is a microcosm of the larger culture.1 There is, however, now a new openness and little disagreement that diversity, equity, and inclusion (DEI) are pertinent and pressing issues in healthcare.2 Consequently, at more than any other time in our history, medicine is primed for transformative work around race. Despite this, institutional responses continue to focus on “checking-the-box” activities—implicit bias training, diversity workshops, etc. These activities certainly have value as initial efforts. However, they often fail to be transformative of thinking, and thus behavior, because they are typically unaccompanied by the opportunity for deep, intentional, and sustained reflection.3 Experiences in the arts and humanities, both self-directed and done collectively, offer a means for producing the transformation of individual thought around race that provides the basis for broader structural change in medicine and the wider society.

Issues of race and racism are historical and complex, nuanced and contextual, charged, and personal. Engagement of these issues in a way that leads to changes in thinking therefore requires humility, vulnerability, and safety and is best done in a supportive community. Structured experiences in the arts and humanities may be useful vehicles for facilitating this change given their emphases on observation before inference, perspective-taking, flexibility in thinking, tolerance for ambiguity, comfort with uncertainty, and their ability to promote empathy, communication skills, and reflection skills.4 Referencing our own personal experiences in academic health systems with existing medical humanities programs, we therefore propose that the next phase of institutional pro-equity/anti-racism efforts includes arts- and humanities-based initiatives to facilitate deep introspection and group conversations that serve to complement and build upon formal DEI didactic presentations, implicit bias workshops, or anti-racism training.

USING THE ARTS AND HUMANITIES TO PROMOTE DIVERSITY, EQUITY, AND INCLUSION

There has traditionally been skepticism of the rigor of the arts and humanities relative to that of the biomedical sciences. While there is a growing body of literature that speaks to not only the subjective but objective impact of the arts and humanities on medical trainees and providers, there are gaps in this area.5 The Fundamental Role of Arts and Humanities in Medical Education (FRAHME) initiative of the American Association of Medical Colleges (AAMC) should help to increase the rigor in this area in coming years.6

We believe arts and humanities programing will be most effective in promoting diversity, equity, and inclusion when they are longitudinal as the impact of single, isolated activities is likely not to be sustained. We also believe that these initiatives should integrate multiple domains of the arts and humanities, be facilitated by trained individuals, and rigorously evaluated. Further, it is our experience that transformative arts and humanities programing is most successful when it developed based on an understanding of the targeted audience. For some institutions, existing humanities programs for medical students can be adapted for residents and faculty with more clinical experience. Even without these pre-existing structures, there is a growing body of literature from which to draw upon to develop programming.6 Specific examples are discussed below to illustrate how various domains of the arts and humanities (Table 1) might be used to promote transformation in thinking about race. The examples are by no means exhaustive but rather illustrate opportunities to build, expand, and strengthen programs.

Table 1 Examples of Using the Arts in DEI Sessions
Full size table

Narrative Medicine

Narrative medicine has been one of the most widely employed and studied of the medical humanities.22 Courses involving writing exercises enlarge one’s capacity to hear, receive, and absorb the stories of others. Creatively wrestling with possibly controversial or painful concepts affords an opportunity for growth in a safe environment and sharing personal writings with colleagues allows for discussion and incorporation of broader perspectives.

Writing prompts and 55-word stories have been successfully employed in many programs to guide these exercises.9, 23 An example of an applied narrative approach is to have a clinician develop and then lead discussion of a case of culture, race, or identity drawn from a personally challenging, humbling, or instructive clinical experience or encounter.8

Literature, Film, and Media

Works of literature, either historical or contemporary, considered in the context of patient care and racial justice can be enormously impactful. Facilitated small group discussion can reap many of the same benefits discussed with narrative medicine with the addition of considering the author’s perspective as a unique and storied voice in the room. Film can be an even more approachable genre. Using multiple modalities and being flexible in modulating approaches based on the participants is crucial since a one-size-fits-all approach is in direct contradistinction to a more pluralistic one.

Performing Arts

Exercises in medical improvisation, script-writing, or role-playing place the performers in a position to empathically relate to the characters they portray.20, 24, 25 The act of embodiment in thought-provoking exercises can serve to jar us from a place of complacency to one of empathy and action while still allowing the participant to return to a “safe” state of normalcy. Acting requires that we deeply root ourselves in the lived experiences of others, an embodiment which allows no distancing and puts the participant directly in contact with the other in a way that third-party discussions and debates can never facilitate.

Visual Arts

Approaching a work of art requires an open mind and the ability to appreciate multiple perspectives. Opening up the experience of interpreting art to a small group allows for a dialectic where one can debate something they believe passionately to be true with others who fundamentally “see” something else in the same artwork, a deeply challenging experience for many in the medical field but crucial to understanding the position, beliefs, and politics of others. By their very nature, the visual arts make objective truths an elusive data set and require, instead, a tolerance for ambiguity and a centering of our subjective interpretation of the world—our unconscious biases.

In the visual arts, these challenging conversations are the starting place, not the ending place, making the art museum a uniquely galvanizing environment for humanistic learning. Sessions conducted in a virtual setting have been very effective as well even with projected images. Exercises such as close-looking or portrait analysis rely on uncovering and acknowledging our cognitive biases in order to move forward to an interpretation as a group.

MOVING BEYOND TALK

It’s important to talk about being “anti-racist” and to appreciate when our communities want to work against problems. And it’s important to check the boxes and attend workshops, to develop a shared language with our colleagues and community that includes shared reflections on our acculturation and roles in society. But transformative change requires that we then apply those learnings, that we engage in active, creative problem solving that goes beyond the lecture and requires us to act in new ways. The humanities—as a discipline, as a creative space, as an experience we all share—can be where we begin to take those actions. This isn’t just an exercise in imagination.