Faculty Feature: Dr. Pier Bryden

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Tell us a bit about yourself.

I’m a clinician at the Hospital for Sick Children where I work in the urgent care clinic in psychiatry. I offer services to young people seen in the emergency department who need to be seen urgently by a psychiatrist, but do not yet need to be admitted into the inpatient unit. I like this work because I don’t know who I will be seeing. I’m also a consultant at our transgender clinic twice a month. I’m not part of the general team, but I am brought in to consult if there are questions about psychiatric issues interfering with youth’s gender transition.

In my academic life, I’m a clinical teacher. I have two academic roles currently. In my role as the Director of Professional Values at the Faculty of Medicine, an aspect of my work is to look at how we can educate faculty around changing professional expectations.  These changes derive from how our communities view professional behaviours by physicians or how our professional values may be evolving as a result of changes in practice or the people entering medicine. When there are concerns about faculty behaviour, another part of my role is to ensure that we address those in a fair and non-punitive way while promoting psychological and cultural safety in our learning and work environments. Finally, I have a smaller role in the medical school, where I work with theme leads to ensure themes are integrated into the curriculum on a longitudinal basis. 

You mentioned your interest with narratives and stories. How do you think stories play out in your clinical or academic roles?

When you encounter a patient for the first time, you are walking into their story, which is so much more complex than that moment of assessment, diagnosis, and potentially treatment. And while there are always emergent circumstances where you are focusing on a very specific issue, you are still intersecting with someone at a specific point in their life’s narrative. In terms of Foundations, we wanted to build a curriculum that conveyed that complexity of human existence. I’m sure we failed because every medical curriculum is doomed to fail in achieving such  an aspirational goal, but the act of ensuring that all of your knowledge is contextualized in a virtual person at least helps with the understanding that there is always story and hopefully provokes an interest in why that person is in front of you. It’s a useful way to encourage learning and engagement with what otherwise can be quite dry information and frameworks. Always thinking about how something fits in someone’s narrative and what our relationship is to that is very important and helpful.

Another interest of mine in medical education is professional identity formation: your stories as  learners and healthcare professionals. If you don’t have an understanding of your story and how it shapes your interactions with your patients, you are not using yourself or looking after yourself as fully as you could. One of my passions is Portfolio because it is a place where learners can look at their narrative as a premedical person transitioning into the medical education environment, and then transitioning into a practitioner role. It’s about understanding what you’re bringing from your prior story and how it will evolve as you become a physician. There’s a lot of social science literature on how we understand ourselves in terms of narratives and how we respond to narratives. 

There is also a meta-narrative of scientific and medical knowledge. I view the medical humanities as an opportunity to learn from health history and paradigm shifts within the philosophy of science. We live in a time where we think we know what we know but so did our predecessors 200 years ago in ways we now know were erroneous and so will people practicing medicine 50 years in the future. The future will always look back on the past and recognize that we were unaware of gaps in our knowledge or that we adopted paradigms that now make no sense. It’s part of this idea that there are always larger stories – in this case, the creation and evolution  of medical knowledge -  in which to situate yourself, your learning and your patients. 

How did your interest in medical humanities and using narratives in the curriculum develop?

I didn’t start off in traditional premedical studies. I had a degree in history and a graduate degree in politics, specializing in political philosophy (prior to medical school). I’ve also been an avid reader my whole life, so when I came to medical education and training, I brought that lens with me.  This helped to make the more challenging education I needed to master more interesting by allowing me to form a narrative. We’ve all gone through the Krebs cycle, cell lines, and the anion gap. In order to wrap my head around these difficult concepts, I’d always imagine the patient I would be seeing in the future and what information I would be using, and that would motivate and engage me enough to learn those concepts. I’d always locate what I was learning in a hypothetical patient or patient story. 

Was there a reason that sparked you to move into medicine?

I just had a lot of “aha” moments. In my political philosophy work, I had thought that I was going to complete a PhD and would teach and write in political philosophy. I was surrounded by people who had gone to university and I was writing sweeping narratives on what society was supposed to be like, but I also recognized that at that stage in my life I had led a sheltered, academic existence and didn’t have a clue about how society worked. I was also coincidentally volunteering in a hospice and I loved meeting people from such a wide range of backgrounds and working with the nurses, physicians and other healthcare workers and caretakers. It was there that I realized I was seeing the practical applications of the concepts that I was thinking about theoretically in my graduate work. This was people helping each other and really engaging in the human condition through exchanges of service, expertise, care and kindness. I realized then that this was the real thing and that I wanted to pursue a career in medicine. After not getting initially because people wondered why I was even knocking on medical school doors with my background, I finally got in. It was a great decision overall, but medicine is also a hard road that I don’t think I understood very well at all—how can you fully understand at the age when you choose medicine its challenges and how it will stretch you? But now, I am never bored and I have learned so much. It is a very good career and I hope that I have contributed in a positive way, but it’s also very hard and I don’t know how we can better help people understand that when they sign up. There are hard careers in the world but medicine presents some unique challenges.

You mentioned you had some challenges with medical school admissions—is that because people weren’t as accepting of a humanities background? Do you think that culture has shifted?

I’ve seen a huge change since the time I applied to medical school. It was difficult for me to shift gears having spent a long period out of science. However, I think that if you’re motivated and bright, which most people who get to the application phase are, with enough support, the medical educational literature says that we all look the same in the end. Medicine is so broad and there is lots of room for different types of brains. Now I see an increased understanding of the importance of diversity—in every version of what that word means. Medical schools are embracing diversity of intellectual background and of thought, as well as cultural background and life experience. What I do wonder is if we are giving enough support for learners who have focused more narrowly in the traditional premedical sciences to make these shifts to other areas of knowledge and vice versa, if we are giving enough support to students with a humanities background to help them learn the science. Another piece the curriculum leadership team is looking at is the new knowledge we need to bring in. For instance, finding a way to introduce data science will be important because it will be such a big part of how patient information will be presented. 

You also mentioned that there are unique challenges that people in this career would have to face. What are some of these challenges, and how can medical humanities help address them?

The challenges are not all about how hard we work, because there are a lot of people who work just as hard as physicians. The uniqueness of medicine that I think we may share with emergency responders and in a different way, individuals in the military or international aid work, is the extremes of life we see. We need to be thoughtful about how this affects us. The medical humanities can offer a balance that reminds us that what we see in our work is not how the rest of the world is experiencing life. Being open to non-medical perspectives is very important. But there are also many ways to achieve these opportunities, not necessarily only through the medical humanities. We aren't all the same, but I think for many people, a book, a film, or music are reminders that there’s more than what’s in front of us—there’s actually a larger world than the work that we’re doing.

When I think about the biggest challenge for myself, it’s the amount of responsibility that we eventually hold for people’s wellbeing and feeling inadequate to hold that responsibility. I think opportunities to read about how other physicians manage this tension and to talk about our experiences are very important. We are going to make mistakes in our careers and it’s good to remind ourselves that we’re part of a larger narrative where we are trying to work to make lives better together.  

And in terms of our own curriculum here at U of T, how do you think it can better address these challenges and help learners develop coping strategies?

I have more questions than answers. What I think a lot about is trust and the challenges of instilling trust when one portion of your community is in an assessment role (faculty) and the other portion (the learners) is being assessed. There has always been a barrier for learners in terms of feeling that they can’t bring all of themselves to their relationships with faculty. We’ve tried to think of a way to separate assessment from mentorship. For example, the academy scholars don’t have a formal assessment role and focus more on providing mentorship opportunities so that learners can be more vulnerable without feeling the associated risk of doing that. 

I’ve also thought about reciprocal mentorship as we are in a period of accelerated change, and we have a more diverse student body in terms of background than our senior leadership and senior faculty. When there is a gap between people’s experience, that can erode trust. But how do we bridge that? How do we teach that and bring people together? It’s a bit of a vague answer, but part of it is more active student involvement in helping co-create the curriculum. Most faculty (who will be you and your colleagues in 10 years) want to help you become a great physician and colleague. If we’re behaving in ways that convey that to you, even when we’re assessing you, that’s probably the biggest single thing we can do to improve the curriculum and how you feel in it. It’s such an interesting question: what helps us build community trust? If we think about what’s changed, students are on every committee and there is understanding that there needs to be more mentorship, more flexibility, and changes to the structure of our clinical work, for example, call schedules. A lot has changed and a lot still needs to be changed, but I do feel hopeful that if we keep plodding along and identifying the barriers to trust and wellbeing,  we will keep moving to where we want to be.

Thank you for these insights. There also seems to be a particular focus on narratives in the field of psychiatry. Do you find this in your clinical work?

It should be every patient, every story, not just in psychiatry. The story that someone chooses to tell you and the story you choose to understand is only one version. I sometimes catch myself “tidying up” this narrative of who a person is and why they’re feeling a certain way, and that’s a form of cognitive bias. Maybe even the patient has a cognitive bias about why they are feeling this way. Part of what I do as a psychiatrist, physician and educator is to say: “This story seems true at this point in time. Let’s look at other potential stories that could be relevant.” I think that if the era of fake news has taught us anything, it’s that we need to challenge ourselves about our own narratives and ask how much they are reliant on so-called facts. It's important to leave time to say: “This is how I’m understanding this. Does that fit with what we’ve talked about and your understanding?” I have more time in psychiatry to do that but I think in any part of medicine, there are ways you can check it’s not just your “tidying.” But also remember the power imbalance that will make patients say that you are right when they are actually feeling uneasy.

Aside from your academic and clinical roles, how has the medical humanities helped you personally?

I love knowledge translation and public writing. I’ve had the privilege of writing two books, one on general psychiatry, and the other on children’s mental health that was recently published. I’ve also started doing a blog and I’ve worked with a TV production company to bring stories about mental health in a way to the public in ways that are honest and promote health. These are things that I just love doing! It is informed by my clinical and academic work, and it makes me enjoy all of my work more—it all comes together. 

Is there a particular book or a film that you’d recommend to our readers?

I really enjoy reading medical memoirs. Looking back, as I was trying to understand what my narrative would be as a physician, because I was coming into medical school as someone who thought they were going to do a doctorate in political philosophy, I was drawn to memoirs by other doctors with unconventional backgrounds. There is an older book called Becoming a Doctor by Melvin Konner, a medical anthropologist who retrained as a physician, and it’s an anthropologist’s perspective on medical training. When the author was a medical student, he was also looking at the organization, structure and narrative of medicine in terms of the socialization that happens as a medical student. I think any medical student who’s a reader would find that very interesting. 

I’m a psychiatrist, so K. Red Field Jamison’s book on her own experience of bipolar disorder would be another recommendation. She writes about the tension between being a professional/academic (she’s a PhD psychologist and internationally renowned researcher on bipolar disorder) and her personal self, who was episodically ill with bipolar disorder. Even though it’s about bipolar disorder, it’s about all of us. All of us will feel ill, vulnerable or fragile at times in our lives. She talks about the self-imposed stigma and how she overcame that to write these books and to acknowledge her own illness. It’s a great book!  

I think it’s interesting to read about the multiple stories people bring into our profession. If you look at medical memoirs and patient memoirs up until recently, they were dominated by writing by upwardly mobile, white people with articulate vocabularies, who tended to be highly educated. More recently, I’ve been reading memoirs from people who have been historically underrepresented as physicians and published writers. This is an exciting and important shift. I think reading memoirs from people with backgrounds different from your own is an important way to educate oneself. It also doesn't have to be reading, podcasts, documentaries, art, music are also great vehicles. I think all of us have narrow perspectives and our own biases as an inevitable result of what is always a restricted life experience. Reading and learning outside your own bias and experience is really important.

Are there any thoughts or advice you would like to share with our medical students?

I was talking to a clerk colleague recently and we were discussing fears. The fears that really helped me in my training were about patients—it wasn’t about me. I had to risk humiliation, shame, and feeling like an idiot to ask when I didn’t know something or say when I was out of my depth. At the end of the day, the patient’s well-being is so much more important than looking like an idiot. That is so easy to say and so hard to do but it is important to recognize that regardless of how it is received, you are a good physician by acknowledging your ignorance because that will help your patient. It really doesn’t matter what anyone thinks of you and how you feel about yourself in that moment, you have done the right thing and helped your patients. Try to worry less about what other people think of you and feeling foolish, and just focus on what the patient needs. Again, that’s easier said than done, but it will keep you and your patients safe. 


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