Renal Failure, Early Online:13, (2011) Copyright Informa Healthcare USA, Inc.

. ISSN 0886-022X print/1525-6049 online DOI: 10.3109/0886022X.2011.589947

CLINICAL STUDY

Creative Writing in Nephrology Education

Kellie Calderon and Kenar D. Jhaveri
Division of Kidney Diseases and Hypertension, Department of Internal Medicine, Hofstra North Shore LIJ School of Medicine, Great Neck, NY, USA

Abstract
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Creative writing has gained some interest in the medical profession in the last decade. There have been a fair amount of publications of using creative writing in the health-care setting as a teaching tool in humanism and doctoring of medicine. As an adjunctive effort, our institution has been experimenting with creative writing exercises to encourage reading in an entertaining way in nephrology. We present a description of two creative tools that we have used to teach renal medicine along with a small pilot study illustrating that the tools were useful in residency education. Keywords: creative writing, nephrology education, physiology, medical students

Creative writing has gained some interest in the medical profession in the last decade. There have been a fair amount of publications of using creative writing in the health-care setting as a teaching tool in humanism and doctoring of medicine.15 In the past, creative writing has been used by physicians to discuss themes including dysphoria, patient care experiences, or humanism in medicine. Writers workshops have been conducted around the world for physicians and physicians in training to improve writing skills, deepen interactions with peers and patients, and increase interest in literature in medicine.1,4 Writing can stimulate residents and medical students to listen to the patients more carefully and appreciate the doctoring of medicine and cultivate a positive attitude toward the patient and the disease state. Creative writing also allows us to learn about the learner. When you think about renal medicine and the teaching of nephrology, do we attempt to see things from the students perspective? Do we consider where the students came from in their academic journey? Do we know how much the students know prior to entering our fellowship? Creative writing might be able to achieve this in certain context.2 Creative writing has not yet been utilized much in teaching medical concepts in medicine or nephrology. Certain medical student study aids such as Made

ridiculously simple series have attempted that and they are very popular among medical students.6 Medical students and residents are often overwhelmed and nd little time for reading as they enter the later portion of their training. As an adjunctive effort, our institution has been experimenting with creative writing exercises to encourage reading in an entertaining way in nephrology. Based on the popular stories of Sherlock Holmes and Watson and the TV show Dr House MD, we developed a dialogue-based storytelling form of creative writing called Detective Nephron.7 The stories unfold interactions between an apprentice (LO Henle) and the guru (Dr. Nephron). Each episode of this cartoonlike comical writing opens with a case that is being presented to the guru by the apprentice. The guru then teaches key important renal teaching points regarding the disorder in question. His thought process is followed to the end where the young apprentice realizes the diagnosis and solves the mystery. For the audience (residents, fellows, medical students), the discussion of disease process between the characters can be a valuable and fun tool to learn nephrology. A series of these have been published in ASN Kidney News.7 The goal of such reading material is to increase interest in reading nephrology-related material and better understanding among our students.

Address correspondence to Kenar D. Jhaveri, Division of Kidney Diseases and Hypertension, Department of Internal Medicine, Hofstra North Shore LIJ School of Medicine, 100 Community Drive, Great Neck, NY 11021, USA. E-mail: kdj200@gmail.com; kjhaveri@nshs.edu Received 28 March 2011; Accepted 17 May 2011

2 K. Calderon and K.D. Jhaveri

A similar approach presents pathophysiology-related topics in nephrology in short story or narrative format. For example, the reninangiotensin system and the tubular glomerular feedback are described from the renin perspective. Such a monologue was written and approved by a group of faculty members for its accuracy among the division (see supplement article Call of Renin available online at http://informahealthcare.com/doc/suppl/10.3109/ 0886022X.2011.589947). To test if creative writing like this would interest and allow for better understanding of a difcult topic, we performed a small pilot study. Twenty-eight medical residents completed a vequestion pretest on basic tubulo-glomerular feedback. They were then randomly assigned to one of two groups of 14 house-staff to receive either a basic review article on the reninangiotensin system or a ctional short story that described the same system from the point of view of the renin enzyme entitled Call of Renin. The next day, a posttest of the same ve questions were administered to the house-staff. Eleven house-staff in each group completed the posttest. Statistical analysis was done using GraphPad statistical software. There was no statistical difference in the pretest scores between the two groups, and both also scored similarly on the posttest (p = 0.69 and 0.71, respectively). However, among residents who reported actual reading of the material provided, there was a statistically signicant difference between pre- and posttest scores in each group (creative writing p = 0.027, t = 2.38; basic review p = 0.019, t = 2.58). Of the house-staff who received the creative writing exercise, 82% (9 of 11) reported reading the material, compared with only 45% (5 of 11) of house-staff who received the basic review article (p = 0.09, Fischers exact test). Seventy-eight percent of the responders who read the creative writing exercise reported that it was a helpful supplemental teaching tool (Table 1). When used by residents, the compared teaching materials had similar effect. However, the benet was the 37% increase in the number of house-staff who read the information when it was delivered as a narrative writing piece. Creative writing exercises can be fun and educational. The value of creative writing for medical education remains a difcult topic and especially hard to measure outcomes. Gull et al.3 used creative writing
Table 1. Pre- and posttest scores of the two modalities. General summary article Pretest scores Posttest scores Received material Read > 50% of material 38% 76% 14 5 Creative writing article 40% 80% 14 9(p = 0.09)

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and created a workshop to encourage volunteer doctors and nonmedical professionals for weeks. While only half of the volunteers completed the workshop, all of them felt that they could reect on medical education better and work as a group more efciently. Most importantly, there was an increase in enjoyment in the task and the understanding of the subject matter. We feel that our attempts are similar. The enthusiasm that is born from these tasks is contagious and it allows for a better understanding of the topic in question. It also allows the educator to understand the learners state of mind and how much he or she truly comprehends the subject matter. It is agreed that an exercise in creating or reading creative writing in nephrology is benecial, yet it remains unclear how transferable the lessons learnt from this pilot study might be. The participants were selfmotivated in our study and the questions were created by the authors leading to a bias. Nevertheless, the exercise was enjoyed by the residents. A larger study with a blinded question designer might be more informative. In summary, we feel that creative writing can be used as an adjunctive tool in nephrology training programs to teach difcult concepts in renal medicine. This can be applied to fellows, residents, and medical students. In a recent review on innovative teaching tools in nephrology, an online survey found such tools to be very useful in increasing recruitment in nephrology.8 Tools such as above can create interest in students to learn more about renal medicine and enthusiasm to make it a career choice. Overall, understanding of the disease state makes one a better physician and allow for better patient care. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES
[1] Reisman A, Hansen H, Rastegar A. The craft of writing: A physician-writers workshop for resident physicians. J Gen Intern Med. 2006;21:11091111. [2] Lujan H, DiCarlo S. Student essay competition: A creative way to learn from our students. Advan in Physiol Edu. 2008;32:168. [3] Gull SE, OFlynn R, Hunter JYL. Creative writing workshops for medical education: Learning from a pilot study with hospital staff. J Med Ethics: Medical Humanities. 2002;28:102104. [4] Koppe H. Beyond the medical record-creative writing workshop for doctors. Primary Care. 2010;10(8):151152. [5] Sampson F, Visser A. Creative writing in health care: A branch of complementary medicine. Patient Educ Couns. 2005;57(1):14. [6] Goldberg S. Clinical Physiology Made Ridiculously Simple. Miami, FL: MedMaster Inc.; 2010. [7] Jhaveri KD. Detective Nephron. ASN Kidney News. 2010;6:16 17. [8] Calderon K, Vij R, Mattana J, Jhaveri KD. Innovative teaching tools in nephrology. Kidney Int. 2011;79:797799.

Renal Failure

THE CALL OF RENIN Authors Kellie Calderon Kenar D. Jhaveri The Call of Renin I knew it was coming. I had just survived the most challenging evening of the precious fty two years on the job, or so I thought. Somehow I sensed the worst was yet to come. . . But I am getting ahead of things. My name is Renin. When I was a baby I was very inactive. Mom nick-named me Pro until I came home to my place just next to Glom Herutown and I grew up to Renin. You see, my identity lies deep within me. . .and not in a metaphorical way. I am the only aspartic acid protease with an S3sp pocket deep in the cleft between the two homologous lobes of my body. Dont go looking on pepsin, cathepsin or chymosin for it! Its my unique active site and it works great. I was raised in a cozy home that is situated between two busy arteries: Avenue A provides transportation to the nearby metropolitan area of Glom Herutown, while Avenue E serves as the exit. There is a second way out of the city once you enter by Avenue A, but most who leave by the yellow trail, have a one way street. Some do return back home!! My job is a very stressful and important one. I never take vacation or holidaysperhaps by choice or perhaps by necessity, I am a workaholic. This day in particular started like most others. I was checking up on my assistant, Ms. Uladensa. Her rst name is Macenzie, but we call her Mac for short. Macs ofce is located at the very end of our friend LO Henles loop, just before it transitions to the DCT parkway. DCT was named after our most renowned king that ruled the kalemialand, Distal Convoluted Tubule, or sometimes also called distal common trafc. Macs job is pretty straightforward: she checks the uid trafc coming by and reports the salt concentration to me. I receive constant emails from her with concentration updates. I have other assistants, too. I pay extra for unlimited monthly text messaging to cover the constant texting from SNS to my granular cells (yes, I get direct innervations from the SNS or the so called sympathetic nervous system, and yes she is always nervous about something.). I heard my receptor friend Bart as my third assistant. He works inside the wall of Avenue A. Hes exible and likes to accommodate trafc as needed, and if there is a decrease in trafc ow hell call me and Ill x the situation. On this fateful evening, I was emailed, texted and called simultaneously by three panic-stricken assistants. An Email from Mac, Text message from SNS and a phone call from Bart.

Re: Urgent!! Sunday, June 6, 2010 6:03 PM From: Mac Uladensa < maculadensa@nephron.com > Add sender to Contacts To: Renin The Great renin@nephron.com Cc: Bar O receptor <bart@nephron.com>, SNS sns@nephron.com Subject URGENT Renin, something big has happened!! The NaCl was at its usual concentration between 30 and 40 mEq/L but it has rapidly dropped to 15 mEq/L! Where is the NaCl?? Yours truly, Mac SNS(Mobile) June 6, 2010:6:10PM: Activating. Release Immediately!! The pressure is down all over; this is serious. You here me!!! Ring Ring: Hello Renin, this is Bart, listen. . ...there is an eerie absence of trafc. . .what is going on? I activated faster than a superhero changing from his business suit to a cape and leotard in a phone booth. I left my granular cell in the home just next to the glomerulus, speeding into the bloodstream. My target was identied and I attacked the rst angiotensinogen I found. The peptide was oating lazily like a ounder. I grabbed an amino acid sequence between my lobes. . .with one cleavage the lazy peptide was gone and the rst angiotensin took off like a shark toward the lungs for further instructions. Ha, ha! I thought, That Leu10-val11 peptide bond is no match for me! This mission was off to a good start. I could feel the intravascular pressure start to rise. A1 must have met up with the converting enzyme in the lungs. I spotted a second school of lazy precursors. I was very condent as I targeted my next victim. As before, I grabbed my target without difculty and swiftly went for the cleavage-but wait! The cleavage was unsuccessful!! My closer evaluation revealed something unusual; something was hindering my cleavage site. I tried to remove it but my efforts were futile. I was inhibited. I had heard tales of A1 unable to convert to A2, and even of A2 being unable to bind to its target receptors. I had laughed at there failures. Now, as I oat lazily like my precursor, inactive like the day I was born as a pro-peptide, I thought of my own futility. My ultimate fear Aliskrenin had arrived. Perhaps the infant Pro will be the next victim. . .

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