From Dilemma to Denouement: Using Literary Techniques to Understand Conflict in Medical Education

Conflict is everywhere.

Without conflict, no story lasts long; indeed, the ubiquitousness of conflict in art and literature mimics reality, confirming conflict's inherent nature in our daily lives. This is logical; we are individuals, living out our own life stories, and individuals are not clones of each other. We disagree. Life doesn’t go our way. There are constraints that limit us. This reality is widely appreciated by those working in medicine, who face a number of conflicts—both internal and external—on a daily basis.

In the literature, conflict plays a meaningful role in creating and evolving stories. Conflict is not just a static presence, but a process through which characters develop and—more importantly—learn and grow. Conflicts lead to crises, which culminate in a climax/breaking point, denouement, and eventual resolution and catharsis.

Given the similarities between literature and reality, it is unsurprising that medical education, the field that trains future healthcare providers to care for humans living out their individual life stories, includes curricular training on conflict. There is no shortage of conflicts in medicine itself: consider disagreements between healthcare providers and patients or healthcare providers with conflicting viewpoints. Medical training programs teach established strategies, such as communication skills frameworks and methods, to help learners handle and resolve such interpersonal conflicts. ¹

However, as the world of literature would suggest, such curricular training is overly narrow and focused. Firstly, these strategies consider only one type of conflict: interpersonal conflict or the conflict between two “characters” in a situation. In the published medical education literature, other, more silent conflicts are seen, which also affect trainee development, learning, and growth. Consider a trainee disagreeing with or feeling left out of shared consultant–patient decision-making, ² trainees unable to pursue perceived morally correct actions, ³ trainees debating whether to risk repercussions and voice concerns, ⁴ and trainees experiencing shame after an identified discrepancy between desired and actual knowledge. ⁵ All of these inner conflicts have been shown to negatively impact learner education and the (trainee-perceived) learning environment, leading to calls to action for solutions and management strategies.

However, commonly-used curricula on conflict resolution do not teach trainees in detail how to resolve conflicts within themselves—or, indeed, focus on resolving any conflict other than interpersonal ones. In fact, many of these conflicts may be challenging for a trainee to navigate or even identify—never mind a well-intentioned educator focused on teaching strategies for combatting learner conflict. That said, there is no standard framework examining the types of conflict trainees face in medical education.

Different disciplines do offer approaches to classifying conflict. In the classical literature, conflict is defined as a struggle or opposition between two forces, ⁶ one or both of which might be internal. Conflict is seen as a constellation that can lead to a number of processes, some potentially harmful for a character (or trainee), and some helpful (such as growth, self-actualization, and identity formation). Popular literary teaching typically describes four main types of conflict: “character versus character,” “character versus self,” “character versus society,” and “character versus nature.” ⁷ Literature, as written art created by humans, harbors similarities to reality, and these literary conflicts represent real-world struggles readers, at the very least, can identify with based on their own lives, ⁸ engaging them more deeply in the story presented. Indeed, the ubiquitous nature of conflict in the literature, ⁹ able to be boiled down into these categories, suggests using this framework as a starting point to study conflict in medical education might be helpful.

But does it work? By substituting “trainee” for “character,” one may find:

Trainee versus Self: This is reminiscent of the previously mentioned intrapersonal struggles, including moral distress, whether to speak up in instances of low psychological safety, and shame after a discovered discrepancy between the standard a trainee meets versus the standard the trainee holds themselves to.

Trainee versus Other Individual: As mentioned previously, most curricular components targeting conflict are focused on interpersonal conflict. Perhaps the most common interpersonal conflict trainees experience is with consultants; trainees describe disagreement regarding patient care plans and clinical management, prioritization of patient needs/requests, feeling coerced into carrying out management plans they feel are morally objectionable, and feeling caught between consultants with differing opinions. ³ This type of conflict (interpersonal) can be exacerbated by differences in power and expertise, as well as a lack of psychological safety, which presents a complex conflict situation. Trainees may also experience conflict with other trainees of the same or similar training status, nurses, allied health professionals, and more. ¹⁰

Trainee versus Society: The tricky balance between providing excellent, timely patient care and affording good learning opportunities to trainees is one that will be familiar to most healthcare providers—and patients.

Trainee versus Nature: Medicine takes a toll on its practitioners, and trainees are far from immune. Burnout, compassion fatigue, and even difficulties with sleep have all been described in trainee populations, who often work long clinical hours, in addition to studying, research, and extracurricular activities, and may struggle to find enough time for self-care.

Beyond simply identifying conflicts, however, there is also the thought that literature may offer strategies in how to manage conflict. The writing process involves working through the process of conflict through its natural stages, such that it (ideally) leads to growth and insight—for the audience/readers, if not for the characters themselves as well.

In addition to being a tool for reflection in its own right, this framework leads to several potential uses in medical education. Narrative medicine is being increasingly used in medical education as a teaching tool to shape attitudes, skills, and knowledge. ¹¹ Using a literary framework (trainee vs self/other/society/nature) in courses teaching narrative medicine could help learners appreciate a more robust viewpoint of the challenges faced—including challenges for which resources and support are not generally available (ie trainee vs society … or, perhaps, patient vs society). This could also help novice writers overcome writer's block, providing a framework for reflection and thought. Furthermore, these four categories could also serve as a model for qualitative medical education researchers seeking deductive or more structured mechanisms to study conflict and triggers of stress for medical learners. Again, using a more robust framework with a wider understanding of conflict can help educators and researchers more fully appreciate the struggles learners face, allowing better support and resources to be provided.

Granted, with every novel framework, challenges do present themselves. The world of literature permits an artistic license from which the world of medicine is estranged. However, the method of thinking, considering, and reflecting—once an individual has had time to acclimatize—is one that not only may harbor benefit in medical education, but in medicine in general, where thinking “outside the box” and working in situations with multiple types and levels of conflict is not unexpected. Additionally, literary conflict frameworks have been broadened at times to include several other categories, such as character versus supernatural. ⁶ This inconsistency suggests that the four-category framework is not sufficient to capture all conflicts in literature—which may also suggest this is not enough to capture all medical education conflicts. However, this framework can serve as a starting point for future reflection and work, and further study and analysis may provide insights to help guide its future use.

By laying out this framework, we already see known conflicts medical learners face falling into manageable, organized categories. By further expanding on the literary model of conflict, we may also find a potential way to help learners manage conflict in medical education, perhaps by incorporating conflict and its resolution into narrative medicine courses. While conflict may be inevitable, its consequences lie on a diverse spectrum. Properly guiding trainees to find their own denouements and resolutions may be a key step in combatting conflicts that threaten the learner experience.