Humanistic care in medical education: an innovative approach through online discussions of literary texts

Background: An online forum was designed for a literature and medicine selective in which undergraduate medical students discussed the poem The Send Off by Sian Hughes. The poem captures a mother’s anguish in aborting a child diagnosed with Down Syndrome. Objective: To analyze the dynamics of the online discussion and its contribution to meaning making, through issues discussed and strategies employed in relation to humanistic care. Method: A close textual analysis of the postings on the online forum was done. Data was coded for emerging themes using the grounded theory. Results: Students discussed issues in the poem in relation to the medical framework, specifically on Down Syndrome. The discussion further explored intra and interpersonal emotional and social implications related to Down Syndrome. Learners used cognitive strategies that required critical analysis of the form and content of the poem. They further employed these strategies in the analysis of peers’ postings. In the interaction with peers, learners drew on experiences and emotions to justify their stand. Conclusion: Online forums which use literary texts as stimuli provide the opportunity for medical students to broaden and deepen their understanding of human experience. The outcome reveals that learners engage in deeper approaches through sustained and interactive discussion with peers. Cognitive and social strategies within a literary framework foster intellectual and emotional understanding of the human condition. Transferable skills relevant to humanistic care that include observation, communication, reflection, critical thinking and professionalism can be nurtured through this approach to better equip the future doctor to provide holistic care.


Introduction
The role of literature in medical education has been established and includes its value in clinical settings and for professional development (O'Toole, 1992;Shapiro & Lie, 2000).Study of literature and medicine in most instances are influenced by an interest in the subject and need to understand the human dimension of medical care (McNaughton, 2000).
Lecturer, Department of Language, Communication and Culture, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Malaysia. Tel: 603 2731 7534 Fax: 603 8656 7229 Email : sheba_dmani@imu.edu.myIn most medical schools, literature and medicine modules are primarily delivered through lectures, seminars and field trips with little attention to the use of online forums.
Online forums are an avenue for creating a community of inquiry which is able to construct meaning through sustained communication (Garrison et al., 2000).They serve as a stage for complex strategies, knowledge and attitudes to be displayed (Ellis et al., 2004).These forums promote interactive, flexible and nurturing discussions which include learners with varying learning styles and may change students' learning experiences (Pirolli, 1991;Anderson, 1996).

Background
In a novel literature and medicine selective offered to second year undergraduate medical students at International Medical University, Kuala Lumpur, Malaysia, tasks were designed to include online forums to encourage sustained discussion of the literary texts (DMani, 2008).The online forum titled Social Forum was not graded as part of the assessment.The forum however drew interest and students posted a substantial number of new and varied discussions on the selected texts although they met face to face everyday throughout the three week course to discuss the texts.An analysis of the usage pattern of the forum revealed that the top ten users were students who generally made little or no contributions in the face to face discussions (DMani & Azman, 2008).
Expanding on the students' interest and ability, and with the aim to involve all students in the discussions, the module was reviewed the following year to include an online forum as part of the assessment.This paper focuses on how and what medical students discussed via an online forum to make meaning of the poem The Send Off by Sian Hughes.

The Send Off by Sian Hughes
For the purpose of this research, one text in particular will be discussed; The Send Off by Sian Hughes (Hughes, 2006).Sian Hughes won the coveted Arvon Poetry competition in 2006 for her poem The Send-Off.Written in response to losing a child through abortion, this poem captures emotions the mother experiences while reminiscing on this compelling process from the time the decision was made to abort her daughter who was diagnosed with Down Syndrome, to her burial.
The poem is a blank verse with run on lines and written in twenty-five stanzas; all are couplets except the twentieth which has three lines.The poem uses simple words that are judicious.The use of metaphors and simile add to the subtlety of the feelings conveyed.The poem is divided into three sections.It begins with the persona, the mother, describing the funeral process followed by a reverie on the mother's own childhood and ends with an explanation to the child for having to meet such a fate; asserting that the child was diagnosed with Down Syndrome (DS).
The tone of the poem is one of deep anguish perhaps due to the retrospective knowledge that the child could actually have been carried to term.In a sense it is an outpouring of the persona's guilt in making the decision.The persona gives us an insight into the feelings of a mother who comes to terms with accepting a child with imperfections.
The typographical arrangement of the poem is a reminder of the connection between poetry and the pictorial.Printed poetry has a strong visual component and this distinctiveness plays a part in saturating its subject with particular significance (Frye, 1957).The words and structure of this poem make you reflect on the incident and hear the agonized mother pleading with her child for release from guilt, or subconsciously, a plea to abort her child again, this time from her thoughts, expressed through this poem.

Study method
The study context was a Literature and Medicine selective offered to forty four second year undergraduate medical students at International Medical University, Malaysia.The students were divided into three groups of almost equal numbers.Each group was assigned one text to discuss online.The texts were uploaded on the e-learning portal using the Moodle platform and could be accessed on the first day of the course.However, students were only required to begin the discussion in the third week of the course.The purpose for doing this was to initially provide students with strategies in using literary tools in the face to face sessions, which were conducted during the first two weeks, before they actually attempted to do so online.The online discussion was also strategized to take place for only three days.This was done to have a more focused, intense discussion.
The researcher also chose not to moderate the discussions as they were part of the summative assessment.
Each group was triggered into beginning the discussion by responding to a question.For this poem, the question was, 'Who is the persona in the poem and what is she expressing?' Students were required to submit a minimum of two posts; one a response to the question and another, a reply to a peer's response with the intention to agree or disagree with the point of view presented.
Data from one group comprising 14 students who discussed the poem The Send Off was analyzed manually using grounded theory (Strauss & Corbin, 1994).There were a total of 48 entries posted on the online forum from 1 st December 2008, 11.47 a.m. to 3 December 2008, 11.14 p.m.The average number of words for each post was 300.Each post was analyzed to identify how and what the students discussed online.The researcher read the posts in the first occasion to get a sense of depth and breadth of the various responses.The posts were then read repeatedly for analysis of qualitative data to gather and review codes in relation to content discussed.This was done as a whole; not taking into consideration if the post was a response to the question or response to peer.
The posts were then organized for analysis of strategies used by dividing them into posts in response to the question and posts in responses to peers' postings.In total, there were 14 postings to the trigger and 34 replies to peers' postings.
The posts were then read again and key themes were formed to categorize the strategies used to answer the question and make meaning of the poem.This was followed by coding the responses to peers' posts to support meaning making.

Results
The key themes are presented and the author has included some quotations which exemplify the scope of discussion and strategies employed.

Scope of discussion
The data was read and analyzed to categorize emerging themes related to the content of the poem.Subsequently, data was analyzed to identify secondary themes that were connected to the main themes.

Medically related issues discussed in the poem
The poem contained the line someone did some counting and they called it trisomy twenty-one.Learners were able to identify that "someone refers to the doctor and the congenital defect in the fetus is DS." Learners were aware that "although not normal, a DS child can live quite an ordinary life." The discussion ventured to how the fetus died; "I am still inclined to believe that it was an abortion rather than a stillborn".The details that were discussed to justify either means were the point in time when DS was detected in the fetus, "Did they detect the genetic anomaly first that led to the abortion of the child or did the child die and then an autopsy revealed the condition?" This led to discussion on the reasons for the mark on the fetus' forehead "The mark on the forehead could be either a deformity of the DS itself, or it could have been formed because of the usage of forceps while removing the dead fetus" and the fact that the fetus' eyes were 'sealed shut'; "I think the eyes being sealed shut does not serve to differentiate between an abortion and a stillborn birth, because in both events, the child's eyes will be closed".

Ethical issues
The learners discussed the right to live, "I don't see why she aborted the baby in the first place" and "is having a genetic abnormality a reason enough to forfeit life".Delving deeper, learners discussed, the mother's reasons for aborting the child; "…surely she must have thought it was in the best interest of the baby since the baby would not lead a happy life if it was born with DS" and "she felt that she would not be able to sufficiently cater to the special needs of this child diagnosed with DS".The role of doctors in taking consent, "many mothers of children with DS related how their doctors had pressurized them into an abortion" and the patient's role in decision making, "the mother never wanted to choose this option and is truly hurt that she had to make a decision, thinking that it was the best at that time" were also considered.

Emotional and Social issues
The learners identified the mother's actions in "comforting the dead child by explaining to her new surroundings; that it is perfectly normal to sleep in a bed without a window; the coffin" and on hindsight that despite her child having DS, she had "hoped to provide her with motherly love and care".The challenges of a mother with DS children was also pointed out, "although the struggles of bringing up a child increased tremendously compared to raising a normal child, these mothers accept the responsibility and the child as a gift from god regardless of the defects".
Learners pondered on the difficulty of making a decision to abort a fetus "The mother must have gone through a tough battle with her selfconscious" and to be empathetic, "...we are in no position to judge the mother for what she did.

The decision could have been made due to numerous possibilities, such as serious medical complications and poor social conditions…and we should not condemn her for it."
Some points covered society's acceptance of DS children, "fear that her child will be ridiculed by society as 'abnormal'"; "all the teasing and stares the child would get." On another context, learners widened the discussion to comment on the motivation for expression; "poets often write to vent out their anger and inner feelings about their personal opinions" and that "sometimes when you have such strong emotions surging inside of you, putting them into words is a form of release." The learners also appreciated the aesthetic value of the poem "I agree that she uses simple words to express herself…simple words with a very deep meaning.I think this style adds to the beauty of the poem." The discussion also saw learners acknowledging the process of making meaning through this form "I think it's beautiful how different opinions are formed from the same text"; "It's fun to see a few lines in this poem can be so debatable."

Strategies employed to understand the poem
The learners responded to the question by identifying the persona and what she was conveying in the poem by elaborating and supporting their opinions through various literary strategies.The learners paraphrased the poem either stanza by stanza or as a whole.Learners also selected significant lines and inferred the meaning; "Mummy has to go now.Sorry we were late.I think this line is her apology for having discovered the genetic anomaly late in the pregnancy." A closer analysis of words used in the poem was done by exploring figurative language; "The writer uses the metaphor of the flower to refer to the child.The word cut suggests that the fetus growing inside her was forcibly separated; in other words, an abortion took place" and choice of words; "The poem says Sorry we were late.It made me wonder who exactly she means by we.I think it implies that she had support from someone else, maybe a family member or a friend…" Learners also studied the form of the poem and noted that the structure gave meaning as "The part where she expresses her deepest pain by letting us know the abortion procedure which severed the life-giving bond she had with her baby is written in 3 lines, not in stanzas of 2 which the entire poem is written in.This extra line is an aberration from the paired lines and can be interpreted as the abnormal extra chromosome which took her baby's life." Another response identified the tone of poem, "the manner in which this line is written sounds clipped and harsh as though the mother is in a hurry to get her guilt and remorse all out quickly in order to subdue the pain."One other way to understand the poem was to associate the background of poet to situation; "I just googled the author's name.Sian Hughes is a single mother with two children.One can only imagine the difficulties a single mother has to endure…" In addition to the strategies used to respond to the trigger, learners used other approaches to respond to peers' posts to clarify, support or refute opinions to understand the poem better.Learners justified their opinions by offering further explanation through textual evidence.However, references were also made to own experiences, "Referring to s6's comment on the motive of the abortion, I agree that it does make one wonder.Here is one reason I can think of on behalf of the author.I personally know mothers with DS children…I would think fear might have dissuaded the writer from carrying the baby to term." Learners who disagreed with opinions, offered alternative points of view for further exploration; "Perhaps the first stanza has a literal meaning instead of a figurative one?It could mean that the mother was literally sorry for being late for the funeral." Making known uncertainty; "I was wondering from the start if the infant in question was still born or aborted by the mother…" and acknowledging uncertainty; "I was wondering the same thing as you, s6.I was thinking if the mother loved her baby so much and was highly anticipating its arrival …why did she terminate the pregnancy in the first place?"was another strategy to discover the meaning of the poem.
Learners also challenged each other by asking for explanations; "…what would your opinions be if we interpreted 'there's a mark on your forehead' as part of the process of delivering a stillborn child?"

Discussion
Findings that are specific to the context of this course and its students inform that meaningful learning can take place through online forums using literary texts.The learners approached the poem The Send Off to answer the initial question posted.They were able to identify the persona and her feelings and thoughts about losing her child.
The content of discussion essentially was related to the issues of DS and how the child died -whether through abortion or stillbirth.Such an issue evidently is close to medical students and they were observant of the physical markers the baby had to justify their opinions.A remarkable observation was made on the structure of the poem and related to the DS diagnosis.Observational skills such as this are transferable to medical decision making (Smith, 1998).The ethical issue on abortion also led to questions on professional conduct.Using literary texts in this sense promotes discussion on medical related issues in a wider perspective.
The influence of the educational culture and schemata of the students was evident and anticipated in this analysis (Fish, 1980).However unlike a study which found medical students less likely to break away from the medical perspective the learners on the online forum explored a wider and deeper scope to have a holistic understanding of the persona (Lahtinen & Torppa, 2007).They empathized with her as a mother and acknowledged the emotions she encountered; relating experiences and knowledge to the situation she was in.They were also aware of the impact of the larger social influences on a mother with a DS child.
The appreciation for the aesthetic value of the poem was pleasantly welcomed and learners were aware of word play and its power in evoking various emotions and in containing underlying meaning.Having such awareness is a skill closely related to the clinical setting where patient's narratives can reveal more information when listened to attentively.
The learners engaged in cognitive and social strategies to arrive at an understanding of the poem.In answering the question, they were able to apply literary devices to analyze the poem.The devices called for careful attention to exploring, connecting ideas, inferring and drawing conclusions.The responses to peers were a platform for information exchange where learners agreed or disagreed with each other.In doing so, they justified their opinions by further drawing contextual evidence from the poem or by providing experiences and researched information.The social exchange favoured open and risk free communication which enabled learners to make known ambiguity, seek clarification and defend opinions.The quality of deep and meaningful approaches to learning facilitated in a computer-conferencing environment has revealed that it fosters higher order thinking skills (Ramsden, 1992;Bullen, 1998).
Results indicate that discussing a literary text independently in an online forum can be accomplished effectively.However, it must be emphasized that the selection of a literary text that lends itself to various slants of study and interpretation is imperative in sustaining the discussion.Online forums create the opportunity to involve all participants in a meaningful manner when the discussion is focused and protected time is allocated to conduct the forum as this leads to intense engagement and inquiry.
Unlike individual assessments, the shared platform nurtured meaning making through exchange of information as a group in order to attain an educational experience.Having a shared response to the text will also facilitate feasible feedback on individual as well as collective strengths and weaknesses.In this context, the researcher did not moderate the discussion however, the outcome can be improved if at the end of the course, noteworthy points are highlighted and key discussions that were missed be identified.

Conclusion
Learning humanistic care through discussions of literary texts via online forums is an innovative method which bridges the gap in interdisciplinary learning.Online forums create the opportunity to be heard in a risk free environment and also nurture social dynamics and sensitivity to emotions, which are imperative skills that medical students need to possess.Alternative approaches to educating healthcare providers on humanistic care should be explored by other disciplines.Further research entails in the area of motivation, comparisons between face to face and online discussions, and strategies in sharing and comparing ideas within a literary framework to facilitate deeper understanding of humanistic care.