This essay encourages the use of literature in medical education and focuses on how psychiatric educators can benefit from a familiarity with the stories of John Steinbeck (1902–1968). Steinbeck was scientifically curious, had a strong capacity to capture ordinary speech, and was an advocate for the disadvantaged. He had a passion for identifying social disruptions and wrote to address these concerns. His core themes and literary qualities provide a rich selection for medical educators: role of “social status” as a critical element in one’s future, attention to issues of personal responsibility, focus on the resilience of the human spirit, and accessibility to the general medical reader.

Compromised or marginalized “social status” is at the core of Steinbeck’s work about the disadvantaged, those fighting for survival. He had a compassionate view of the marginalized and those identified as misfits, and he vividly portrayed the resultant stress and violence of those displacements. Although he acknowledged the social sources of inadequacy, humiliation, and violence, he also maintained an expectation of personal responsibility. If he were writing today, he would be focused on the similar circumstances of ethnic minorities, the unemployed, sex workers, and the chronically mentally ill.

Steinbeck had a keen sense for social status and its consequences. His writings ranged from the examination of the imbalance of power between a stern father and his son, as in The Red Pony, to the downward mobility in economic crisis as in Grapes of Wrath and In Dubious Battle. His “there and then” stories from the Great Depression are surprisingly relevant to the “here and now” of our current economic distress. Steinbeck described the tragedy of wasted lives and missed opportunities. His works focused on the “human dimension,” allowing for their ongoing relevancy.

Using literature to teach medicine and psychiatry has had many educational precursors. The value of stories to provide an evocation of multiple meanings, engagement, and reflection is well established. Stone’s (1) Abnormal Personality through Literature provides useful selections from multiple authors to describe psychiatric conditions. Rita Charon (2, 3), an internist at Columbia University, has developed a narrative medicine program and describes the importance of “narrative competence,” the ability to learn from stories, as a significant skill for physicians. She has emphasized physicians’ doing their own writing and developing self-reflective capacity. Alice Flaherty (4), a neurologist, reviews notable authors such as George Orwell and William Faulkner, provides reflections on literary creativity, and discusses limbic system contributions. She writes provocatively about “metaphor, the inner voice, and the muse.”

This essay focuses on incorporating Steinbeck’s compelling stories into clinical teaching to provide insight into the lives of patients.

Steinbeck was born and raised in Salinas, Calif., near Monterey. He was a student of Milton, Shakespeare, Dostoyevsky, Flaubert, Sir Walter Scott, and Thomas Hardy (5). His ordinary language belied his strong grasp of classical literature. In addition to his literary interests, he studied marine biology at Stanford University. He was intrigued by the multiple determinants of behavior: biological, psychological, and social.

Like Thomas Hardy, Steinbeck’s best work took place in the agricultural region he knew well. The geographical settings for both Of Mice and Men (1937) and The Red Pony (1933) were located near his birthplace. The 1930s were a highly productive period for Steinbeck, when he also wrote the Pulitzer winning Grapes of Wrath (1939).

Steinbeck’s Perspective and Presentation

Steinbeck is particularly helpful in addressing the social consequences of those displaced and humiliated; many of his characters find themselves in prison or tent cities or injured. His insightful depiction of social distress takes his work beyond a simple recollection of statistics or polemics. If he had simply provided a dogmatic interpretation of the Great Depression, his works would have fallen from readers’ interests.

Steinbeck excels at providing accessible characters, and his narration is rooted in an oral tradition. He read his stories out loud, testing the underlying rhythm. He can speak to a general audience. Many medical students would have encountered his work during high school and would not have needed to be English majors to grasp it. Steinbeck’s strong sense of humanity and bawdy humor enlivened his work and expanded its availability to general readers.

His short stories can be read in a single sitting. Reading them in their entirety is important for having a sense of the vigorous language, social confrontations, and character development. Longer works could be viewed as films; for example, the 1940 adaptation of Grapes of Wrath with Henry Fonda has a particular power and immediacy.

Usefulness for Medical Students

Steinbeck wrote a number of shorter works such as The Red Pony and Of Mice and Men that would be accessible to busy medical students. He had a gift for expressing basic issues such as tenderness, grief, loss of ideals, and inadequacy. Despite their circumstances, many of his characters have resilience and a will to survive. How individuals find hope and courage in dire circumstances are important learning opportunities. The lead characters demonstrate resilience in attending to overwhelming situations.

The Red Pony

In The Red Pony, the protagonist, 10-year-old Jody, is not socially marginalized by poverty but by parental aloofness. His father has stern and unachievable expectations. Jody has responsibility beyond his legitimate capacity to perform. The father’s giving Jody a pony to manage on his own is an empathic failure. The pony escapes, returns, and then becomes seriously ill. Jody encounters deep feelings of loss and incompetence through his inability to care for his gift pony.

Despite Jody’s best attempts, the pony gradually dies because of “strangles,” an inflamed mucous membrane. Jody enlisted the help of Billy Buck, a farm hand, to provide extra rubdowns and attention to the pony’s survival. Billy’s interventions included a tracheotomy as a valiant but failed attempt to save the pony’s life (6):

To compound his feeling of uselessness, Jody believed that he had disappointed his father by not providing adequate care for his pony.

For medical students who may not have experienced the feelings of powerlessness and ugliness surrounding death, this story excels at presenting feelings of inadequacy. For students, the death of a seriously ill pediatric patient can produce intense feelings of “not doing enough” or “not knowing enough.” Many clinical teachers can remember their own experiences of having felt sorely wanting in a serious clinical situation.

Steinbeck’s story opens the door to discuss a typically unspoken clinical experience. There is a teaching opportunity for the translation from the feelings of losing a beloved pet to the experience of losing a patient. Unlike the stern father in the story, educators can provide a context for the sense of loss, guilt, and shame. Similar to the use of fables, Steinbeck’s story provides an avenue to discuss feelings about responsibility in death that might not be available if it were addressed “head on” in a case discussion.

Of Mice and Men

The setting for Of Mice and Men is a California ranch, where migrant agricultural workers are hired to bring in the crop. The story invokes multiple types of violence generated by developmental disability, interpersonal deficiencies, and social stresses (migrants versus owners). The migrants, George Milton and Lenny, a large and developmentally disabled man, sign on as workers. George, in an act of good will, promised Lenny’s mother to take care of him. Although a nonrelative, George has tenacity in staying with Lenny, who loses jobs for them. In their previous job, Lenny had frightened a local woman by his advances and they had to leave. Lenny simply wants to pet “soft things” such as rabbits, mice, or women’s hair. Despite Lenny’s recurrent social and legal altercations, George steadfastly maintains his protective role to assist in Lenny’s survival.

George’s protection of Lenny is misunderstood in the cynical world of migrant workers and bosses. His attempt to preserve Lenny’s earnings is challenged by the foreman (7):

“Say—what are you sellin’?… I said what stake do you have in this guy? You takin’ his pay away from him?”

“No. ’course I ain’t. Why ya think I’m sellin’ him out?”

“… I said what stake do you have in this guy? You takin’ his pay away from him?”

“No. ’Course I ain’t. Why ya think I’m sellin’ him out?”

The foreman, Curley, is an enduring bully and amateur boxer. He believes that he can take advantage of the migrant workers and provokes Lenny into a fight. Lenny, known for his strength, grabs the foreman’s fist and crushes it in his hand. The foreman’s slatternly wife then becomes interested in Lenny because of his ability to stand up to her abusive husband. Curley’s irresponsible confrontation with Lenny starts a cascade of tragic consequences.

Lenny responds to advances by Curley’s wife, but he frightens her as he begins to stroke her hair as he had with his rabbits. She screams, and Lenny inadvertently suffocates her while trying to stop her screaming. Lenny confesses the killing to George, who sends Lenny to a streambed where they have hidden previously. At the site, George shoots Lenny with a stolen pistol to keep him from falling into the hands of the pursuing mob. Lenny receives a quick death while he is contentedly recounting that he and George will have a farm where he can raise rabbits, his long-held hope.

Steinbeck’s story evokes a challenging issue of responsibility and justice. A death has occurred, but the reader is left with the question of whether Lenny committed murder. The medical educator can consider issues of “diminished capacity” and the assessment of what constitutes a crime. Although Steinbeck did not provide an early life history, an individual like Lenny would have a history of leaving school early, markedly limited intelligence scores, and interpersonal failures.

Lenny did not have an “evil act” in mind when he was stroking Curley’s wife’s hair. He was frightened and inept but not murderous when he suffocated her. Medical educators could discuss the critical difference of intent between murder and manslaughter; the issue is not a fine point of forensic psychiatry, but the understanding of human limitation and reduced responsibility is. Lenny provides an impressive opportunity to consider the necessary struggle in making sense of criminal responsibility.

George was placing himself at legal risk by shooting Lenny. George provided Lenny the opportunity to dream of a home with rabbits rather than a last encounter with an avenging mob. He wanted to protect simple-minded Lenny from the rage of the townspeople and a potentially cruel death, such as a lynching. George’s actions could be viewed as a compassionate euthanasia in preventing Lenny’s suffering.

Curly, the foreman who sparked the series of events, has substantial responsibility for the tragedy but is not in the forefront when Lenny’s death occurs. His culpability is cloaked by the number of events that have transpired. The irony is that the serious consequences of death and the threat of a murder charge are borne by the migrants.

The sparse structure of the story provokes the medical student reader and educator to consider the difficult issues of criminal responsibility and reflect on those who are charged with violent crimes. As we recognize the frequency of legal complications in our patients’ lives, we need to think more deeply about how those events occurred.

As medical teachers, we typically transmute specific case histories into useful teaching experiences for students. Literary stories have similar capacity to engage our students in broadening their experiences and improving understanding of the complexities of patients’ lives. Marginalized patients suffer a heavy burden of illness, injury, and death. Steinbeck’s portrayals of hope and caring despite tragic circumstances are an important teaching resource.

The common thread in the stories discussed here is the challenge of personal responsibility in death, whether it is through natural causes or violence. The stories do not provide an answer to these difficult experiences but serve as points of reflection for students on how they might respond in similar circumstances. Students are given the opportunity to make sense of premature death, unintended death, and euthanasia. Steinbeck opens the door to subjects that may have otherwise seemed distant to medical students.

Utilizing our appreciation of the power of stories, educators can provide a compelling picture of the human costs of being marginalized and experiencing inadequacy and being both receivers and perpetrators of violence. Students are likely to have greater exposure to patients whose lives are marked by the deterioration of their social standing and circumstances. The ability to endure those experiences is important for both our patients and our students.

An earlier version of this paper was presented at ADMSEP in Park City, UT, on June 23, 2007. Disclosures of Academic Psychiatry editors are published in each January issue.