Using literature as the framework for a new course.

OBJECTIVE: The award-winning book The Spirit Catches You and You Fall Down,(1) a true story of the collision between two cultures (American and Hmong) with heartrending consequences for the patient, the patient's family, and the medical professionals who care for them, has been favorably reviewed(2) and used to stimulate teaching of cultural diversity, ethics, and professionalism to students and residents. We used it as a required text for a new Patient Doctor Society (PDS) course for 184 first- and second-year medical students. This report describes the scope and contexts in which the book was used to meet specific course goals. DESCRIPTION: PDS is a required 90-hour introduction to medical interviewing, which integrates ethics, communication, clinical reasoning, cultural diversity, humanities, spirituality, integrative medicine, nutrition, and behavioral science. To provide a common experience among these diverse topics, faculty members were asked to use examples from the book to achieve their learning objectives. A required faculty development session illustrated strategies for effectively using the text. Focusing on chapter 13 ("Code X"), dramatic portrayals of differences in beliefs about end-of-life care and clinician-family communication, facilitated the introduction of methods including point-of-view writing, role-plays, and faculty-facilitated discussions as techniques for meeting course objectives. At PDS orientation, we used the same chapter, and had faculty members lead small groups of students using the teaching techniques they acquired. About 90% of students read the book prior to orientation. Students favorably reviewed this three-hour session. For the ethics session, unfacilitated small groups of students were asked to identify and discuss the ethical issues in chapter 11 ("The Big One"), which describes a major turning point in the health care provided to the text's central character, Lia. Each group presented its "moral diagnosis" and ethical arguments for resolution. Class discussion then focused on the diverse views presented, to emphasize the importance of justifying decisions and to practice using tools of ethical analysis. In the communication skills workshop, we excerpted dramatic readings from the book. Faculty members played the roles of the author, the patient's mother, and one of Lia's physicians. The interaction became a dialogue to illustrate the points of view of the participants. The dialogue was used to stimulate discussion about potential pitfalls in physician-patient communication and understanding. In a medical humanities session, excerpts from the book were compared with poetry explicating themes of physician arrogance and humility. DISCUSSION: The Spirit Catches You and You Fall Down provides a context appropriate to teaching students how to listen to, and learn from patient stories. The story will be reintroduced in the pediatrics clerkship. Caution will be exercised to (1) avoid overexposure to the text, (2) counteract the potential to interpret the story too narrowly, and (3) assure that faculty become familiar with the text and its uses. We intend to track outcomes in knowledge, skills and attitudes for each content area, and observe the degree that the book facilitates achievement of objectives. We will follow several cohorts of students to verify longitudinally the learning effects observed.