Over the past 30 years, novels, short stories, poems, and other forms of narrative have increasingly found their way into medical education to be used as resources for teaching students to become "narratively" competent (1)—better diagnosticians, with an improved ability to listen and understand a patient's story and experience of illness and develop an empathic patient-physician relationship (2). Literature may teach students to be more sensitive doctors in the everyday practice of medicine—bringing greater care to those who are ailing, fearful, or faced with terrible suffering (3). A recent study found that almost one-half of the medical schools in the United States that were surveyed used literary arts in the curriculum, and more than two-thirds provided extracurricular humanities programs (4).

This study describes the use of the literary classic short story "The Yellow Wallpaper" (5) by Charlotte Perkins Gilman (1892) to illustrate the lecture topic of postpartum psychotic depression in a human behavior course for sophomore medical students. Loosely based on the author's life (6), the story's young narrator struggles to overcome her "temporary nervous depression" through the physician-prescribed "rest cure," supervised by her physician-husband. This medical therapy was introduced as treatment for women with "nervous conditions" by the prominent 19th-century neurologist Silas Weir Mitchell (6). During her isolation, the protagonist keeps a diary of her descent into psychosis, with the yellow wallpaper taking on hallucinatory properties as "repellent, almost revolting; a smoldering unclean yellow, strangely faded by the slow turning sunlight."

The Spring 2003 Literature and Medicine session for the sophomore human behavior class was the first exercise using literature in this course. One of the stated teaching goals of this lecture-based course focusing on DSM-IV-TR-based psychopathology was to reduce students' possible learned stigmatization of mental illness. Learning objectives for this session were to:

One week prior to the session, the human behavior course director sent sophomore medical students (N=156) a memo describing the optional literature session, with a link to a web access to "The Yellow Wallpaper." We divided students into eight groups of eight to 10 students each, assigned a small group facilitator, and awarded an extra credit point for participating.

A 2-hour training meeting organized by a literary expert and the human behavior course director prepared the multidisciplinary, volunteer faculty. Three psychiatrists; a physician and master’s level social worker; an internist; a dermatologist; and a literature professor, expert in medical humanities, were facilitators. Faculty discussed learning objectives and ways in which they could engage students in the activity.

Each student group met for 1 hour with a facilitator. During this time, faculty asked students to discuss their interpretation of a short story. Clinical, ethical, and professional issues raised by the story were outlined as possible discussion points for facilitators and included diagnostic criteria for postpartum psychotic depression, historical treatment options, listening to patients, pitfalls in treating family members, communication challenges physicians face when treating psychotic patients, the historical role of women in the family, and the paternalistic role of physicians. At the end of the session, students completed a short evaluation form rating three statements using a 5-item Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree):

A fourth item asked students to "rate the session overall," ranging from 1=poor to 5=excellent. Space was allocated for students to provide written comments, and facilitators also provided written comments for the exercise. To ensure confidentiality of responses, students completed evaluations anonymously, without facilitators observing, and placed them in a large envelope supplied for each group. A staff member collected these envelopes afterward.

Due to the positive nature of student evaluations, authors later decided to publish results. They obtained appropriate approval from the Institutional Review Board of the University of Oklahoma Health Sciences Center, consistent with policies for publishing educational studies.

Of 118 students who participated in the session, 94 (80%) completed the evaluation. Seventy students (75%) agreed or strongly agreed that the literature session was useful to their medical education. Eighty-five (91%) agreed or strongly agreed that the session held their interest. Seventy-seven (82%) agreed or strongly agreed to recommend repetition of the session the next year, and 79 (84%) rated the overall session as excellent or near excellent. One facilitator for the two sessions had the highest number of items that were endorsed "strongly agree" (N=15, 82% for item 1; N=17, 94% for item 2; and N=17, 94% for item 3), and 94% (N=17) of his student comments rated the session overall as "excellent." Most ratings for other facilitators were in the "agree" to "strongly agree" or "neutral" to "excellent" range.

Two psychiatrist authors (A and B) independently classified open-ended comments into three groups—positive, negative, and neutral—for students and facilitators. For a total of 45 student comments, the following classifications were obtained: positive: A=38, B=37; negative: A=5, B=6; and neutral: A and B=2. Among the positive comments were, "It was very interesting to be able to relate a classic short story to current medical illnesses. It shows that things have not changed all that much. Good session!" Similarly, another participant stated, "I have trouble reading into stories about mental illness and picking out the symbolism and the signs. This session helped to pick apart the components and identify the illness." "Please keep sessions like this available. They force medical students to bend their minds in ways they usually do not," commented another. Negative comments included, "It's a good break from lecture but not very pertinent to our medical education," and "I would like to read a more modern story that is a little more relevant to today's medicine versus medicine in the 1800s." The same facilitator with high ratings, previously described, had nine positive and zero neutral or negative comments.

Facilitators were more conservative in their comments, with faculty A and B assessing two comments as positive and three as neutral. Three facilitators returned the evaluations without comments recorded. Positive remarks included, "I was pleasantly surprised by the level of participation and spontaneity. There was a variety of perspectives shared by the students …," and "I found the format of the guide for facilitators most helpful." On the neutral side, some facilitators noted a variation in student engagement. One stated, "Hopefully it was helpful to them—they do very different scientific readings," and another said, "Some of the concepts explored in the story were difficult for brand new practitioners to appreciate but I think they enjoyed the experience."

Medical educators have noted that an overcrowded pre-clinical medical curriculum with a heavy science course load and competitive atmosphere can overwhelm medical students and make it difficult for them to explore their own personal spiritual or humanistic values (7).

Students in our literature exercise were quite receptive to using "The Yellow Wallpaper" as a type of psychiatric case presentation to integrate lecture and textbook material related to the topic of psychotic depression. As one student noted, "It put some of the stuff we learned in lecture in perspective." Positive comments far outnumbered negative ones, with descriptors such as "insightful," "interesting and relevant," "fun," "stimulating," and "wonderful change of pace." Similarly, 75% or more favorably assessed all four items on the evaluation. Medical educators have noted students' strong acceptance of literature in their curriculum (8), which may be in part due to its addition of humanism to scientific aspects of medicine (7). Literature's appeal to physicians may also derive from its ability to evoke a sense of discomfort and vulnerability in readers (9), which facilitates a more empathic connection with patients, and from its expression of complex aspects of medicine that are difficult to articulate (1).

The few negative comments from students and the neutral comments from several facilitators echo a more conservative view toward the medical humanities expressed by some authors (10). Medical educators have emphasized the importance of organizing the humanities appropriately in a dense curriculum and measuring the impact of the humanities on learning and medical practice (4). Measuring treatment outcome would be complex and challenging, encompassing diverse elements such as morbidity, mortality, quality of life, and satisfaction of the patient and the physician. Follow-up of our medical student participants during their psychiatry clerkship could assess whether students believed that this exercise in the pre-clinical years prepared them to deal more effectively with psychiatric patients. Although logistically difficult, follow-up of participants when they are in medical practice could assess whether this exercise was perceived as having a lasting benefit to their rapport with and treatment of mentally ill patients.

Among limitations to this study, there was no control group of students who did not participate in the exercise. A control group from the same or different institution may have assessed a different type of interactive exercise such as a "problem-based" approach, which could have enhanced understanding of postpartum psychotic depression.

Additionally, in considering raters' assessments of student comments, it is pertinent to note that these raters were also facilitators. It is possible that their ratings of their own students' comments had an unintentional bias. However, their ratings were quite similar. We were also unable to conclude whether awarding an extra credit point for participation influenced students' attitudes.

Another limitation is that the student evaluation form did not assess each individual learning objective. Thus, with the exception of several spontaneous comments by students, we did not quantify how well the literature session developed the topics of postpartum psychotic depression, the doctor-patient relationship, psychosocial issues, and literary style. In repeating this exercise during the next academic year, we plan to explore the effectiveness of accomplishing these specific objectives. In addition to measuring the acceptability of medically relevant literature to students, future educational studies should assess explicit ways in which the humanities could enhance learning of more abstract qualities such as empathy, tolerance, and communication.