Finding a Voice

November 14th, 2014

The Absolutely cast photo n

In a small off-Broadway theatre in NYC, it’s opening night for a new play, The Absolutely, Positively, Forget About it, Last Night at Von Dahm’s Sports Bar, Wing Hut and Karaoke Palace. The actors run through their lines one last time before heading to wardrobe, the props are on set, the music and lighting are cued. But there is something a bit unusual about this performance. The cast is composed of stutterers who have taken to the stage to face their fears of performing in public and to show others that it can be done.

Kathe Mull, the director of the play, chose a comedy in part to stretch the actors' ability. She encourages the actors to look at the audience, rather than looking down or to each other, to cover up the trouble they have voicing their words. On stage, the actors perform their lines with only occasional stuttering. Sue Camlin plays a bar owner who is closing down after decades in business, forced out by a new hip bar across the street that is part of the gentrification of her Philadelphia neighborhood. Her friends join her to help pack, and, in the process, they uncover an interesting piece of the bar’s history.

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Photo courtesy of Tony Troiano, Orazio Fotografik

The play is a production of the Actors International Theatre, a company dedicated to giving voice to people with disabilities. Katherine Filer is the founding director of the company and a member of a New Jersey chapter of the National Stuttering Association (NSA). According to the NSA, more than 3 million American adults stutter. Stuttering is a disruption of the fluidity of speech, and while there is no cure available, early recognition and speech therapy can help. Although the specific cause of the condition is not known and is likely due to several factors, people who stutter are often thought to be intellectually and emotionally impaired, neither of which is true.

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Photo courtesy of Tony Troiano, Orazio Fotografik

Ms. Filer met her fellow cast members through the New Jersey chapter of NSA. While none are professional actors, this is the second time that she, Sue Camlin and Lucy Reed have appeared on stage together, something neither would have dreamed of doing earlier in their lives. Sue Camlin is a retired prekindergarten teacher. In high school she was not allowed to perform in school plays because of her stuttering and had to work behind scenes helping with makeup. Lucy Reed is a speech therapist; she avoided a career that involved speaking in public or to clients. "It's a label that individuals have a hard time overcoming," says Lucy.

Sue wonders whether people will hang up on her when she calls once they hear her stutter. Telling jokes is impossible because people who stutter can have a difficult time with punch lines. Singing is easier, and the play features several songs for the group to perform together. Familiarity with the lines, focusing attention on memorizing the script, and patience with the pacing of the delivery all contribute to the success of the production.

The play's ending involves a simple tweet about the "discovery" that brings customers back from the hip place across the street and rescues the business for Sue. Communicating easily via social media emphasizes the sharp contrast these actors face as they struggle to speak fluidly. Tweeting is one way of being heard, but still, nothing beats conversation. The cast of "…Last Night" knows that to be true.

The Absolutely, Positively, Forget About it, Last Night at Von Dahm’s Sports Bar, Wing Hut and Karaoke Palace, a one act play by Sean Grennan. For more information, please contact

actorsinternationaltheatre.org

ActorsInternationalTheatre@gmail.com

Medical Humanities - Initiating the Journey at Xavier University School of Medicine

August 26th, 2014

Dr P. Ravi Shankar has been facilitating medical humanities sessions for over eight years, first in Nepal and currently in Aruba in the Dutch Caribbean. He has a keen interest in and has written extensively on the subject. He has previously written several pieces for the Literature, Arts, and Medicine blog.

I have always enjoyed facilitating medical humanities sessions right from the time I facilitated my first voluntary module for interested students at the Manipal College of Medical Sciences, Pokhara, Nepal in 2007. The energy level during the inaugural module was incredible. The participants, both students and faculty, and I really enjoyed the evening sessions and the feeling of freedom and discovery as we did various activities and discussed different issues. We had a lot of fun.

When I joined Xavier University School of Medicine (XUSOM), on the beautiful island of Aruba in January 2013, the Dean, Dr Dubey was keen that I facilitate a medical humanities module for the undergraduate medical (MD) students. The school had just shifted to an integrated, organ system-based curriculum from the traditional discipline based model common in offshore Caribbean medical schools. Didactic lectures were the main teaching-learning methodology but the school was working towards introducing small group activities and problem based learning sessions. I decided to facilitate a short medical humanities (MH) module for the incoming first semester students.

At that time the school had only lecture rooms and a traditional desk and chair seating arrangement. Luckily the desks could be rearranged, and I conducted my first session in the lecture hall with the students arranged in four small groups. Some of the students had completed a premedical course of study in the institution and were only familiar with lecture based-teaching. Small group activity was something new for them. Medical humanities do not occupy an important position in the United States Medical Licensing Exam (USMLE) Step 1, and students in Caribbean medical schools focus on step 1 preparations. Subjects which are not tested or tested less in step 1 are not considered important. MH is thus not commonly offered in offshore schools.

The first group of students: I concentrated on six topics for the inaugural and subsequent medical humanities modules. These were empathy, the patient, the family, the doctor, the patient-doctor relationship, and the medical student. The modules were activity based and I used case scenarios, role-plays, debates and paintings to explore different subjects. The learning objectives of each session were listed in the study outline posted on the class server and also highlighted at the beginning of the sessions. For example, for the session 'The doctor' had these objectives:

At the end of this session students will be able to:
•Obtain a perspective on what it means to be a doctor
•Explore balancing a meaningful personal life with a busy and rewarding professional career
•Understand 'certain' influences and pressures on a doctor today
•Interpret the changing role of doctors through paintings and stories

Certain students enjoyed the freedom and flexibility offered by the module while others tended to 'misuse' the freedom. I had a few disciplinary issues which I had to deal with carefully as I did not want students to feel intimidated. I did not confront the students with disciplinary problems during the class but had a quiet word with some of them after the session. The formative assessment rubric addressed issues like attendance, punctuality, discipline and commitment and students who worked harder and showed greater commitment performed better in the assessment. Also for each session each small group had a group leader who was responsible for keeping the group active and focused on various tasks. The role was rotated during different sessions. I wanted them active, focused and interested in the activities and the subject. Among the various activities employed, students eventually did well in interpreting paintings and in the debates. The role-plays however needed more work. They often did not explore the issues in sufficient depth and students felt inhibited to act out certain scenarios in front of their classmates. This was in contrast to the students in Nepal who had enjoyed the role-plays with their skits and acting became richer and more complex as the module progressed.

Two of the role-plays I introduced were:
1. Ms. Mohini is a 28 year old lady from South Asia who was trafficked and was compelled to become a commercial sex worker. After ten years of service she was sent back to her country and village as she became HIV positive. The disease is at an advanced stage and she has no money for treatment. Her family has reluctantly allowed her to stay with them but is not happy that a retired prostitute is living with them. Explore what it means to be sick using a role-play. (Used during the session 'What it means to be sick')
2. Dr. Richard is an Internal medicine specialist in Toronto. He has been treating a twenty-two year old college student named Rachel for the last five years. The lady suffers from severe attacks of migraine and is on drug prophylaxis. Richard has realized that he is in love with Rachel. He wants to live happily ever after with her. However, he is not sure about whether it would be correct for a doctor to marry his young female patient. Analyze the issues involved using a role-play. (Used during the session 'The patient-doctor relationship')

Among the different cohorts of first semester students I found the fall 2013 and the spring 2014 cohorts to be the most interested and active (XUSOM, like most offshore Caribbean medical schools, admits students three times a year in January, May and September). These students created interesting role-plays to explore various issues based on the scenarios provided. The debates and the interpretation of paintings were also rich and varied. I enjoyed facilitating these groups. These two cohorts had a few students who were active, dynamic and committed and with good leadership skills. They were able to motivate and stimulate their colleagues to give their best. They also had good acting skills, which was useful during the role-plays. With greater exposure to small group learning these cohorts were more comfortable with group work and the academically stronger students were more willing to support students who were less strong academically. Class sizes at XUSOM are small and till date around 90 students have completed the program.

Co-facilitators:

At XUSOM many students, though American or Canadian citizens, are of South Asian or Middle Eastern descent. There were no major cultural and other problems involved for me in facilitating this group of students. Many students were interested in this new perspective and in understanding the art of medicine. XUSOM also offers courses in English and scientific communication to premedical students and the faculty members teaching this subject eventually joined me as co facilitators during the module. They were from a liberal arts background and were able to offer a 'different' (often a layperson) perspective during the various activities and the discussion. A challenge I faced similar to Nepal was that not many 'medical school faculty' were interested in MH and in co-facilitating the module, though two or three did attend certain sessions.

Small group learning room and other developments:

Over the preceding twenty-month period MH has become an accepted part of the school curriculum. The school created a separate room dedicated to small group learning with comfortable seating, white boards, flip charts and projection facilities. The room is now being used for various small group activities including problem based-learning. Slowly there is a greater number of small group learning and self-directed learning activities at the school. MH is now an established discipline at the school and the module is a part of the patient, doctor and society module for first semester students. Students' ability to show empathy, make their patient feel comfortable and obtain a proper history is assessed at the end of the first semester using standardized patients. Students also visit a local general practitioner every fortnight to learn history taking skills and interact with patients. I am sure MH will progress and grow in the sunny, hospitable climate of the one happy island of Aruba in the Southern Caribbean.

You can learn more about the MH modules in a forthcoming article in the Asian Journal of Medical Sciences titled 'Four semesters of medical humanities at the Xavier University School of Medicine, Aruba.' (in press)
Photos courtesy of Dr. P. Ravi Shankar

Reading the Body: Live!

July 16th, 2014

Stacy Bodziak, Managing Editor, Bellevue Literary Review

Not many literary evenings are divided into sections on "Dissection," "Bone," "Brain," "HEENT," and "Heart," but then again, it's not often that the readings are selected to complement Frank Netter's iconic illustrations. This past spring, the Bellevue Literary Review (BLR), a journal published by NYU School of Medicine, hosted "Reading the Body: Live!" an evening of poetry and prose that celebrated the closing night of the MSB Gallery's exhibit honoring Netter, "The Michelangelo of Medicine."

The featured readings - which span the BLR's thirteen-year archive - were brought to life by Kelly AuCoin and Carolyn Baeumler, talented actors that captivated the audience. Introductory remarks were made by Danielle Ofri, MD, PhD, editor-in-chief of the BLR, and Matthew Vorsanger, MD, Chief Resident, Internal Medicine. The evening was sponsored by Division of Medical Humanities and the Master Scholars Program in Humanistic Medicine.

This div will be replaced by the JW Player.

Two Doctors, Two Generations: Q&A with Dr. Barron Lerner

June 23rd, 2014

On May 6, 2014, Barron Lerner, MD, PhD, kicked off the Lerner Lectureship series with a talk that explored the evolution of medical ethics through the lens of his father's and his own practice of medicine. Dr. Lerner's father, Phillip I. Lerner, MD, was "a revered clinician, teacher and researcher who always put his patients first, but also a physician willing to 'play God,' opposing the very revolution in patients' rights that his son was studying and teaching to his own medical students." The talk built upon Dr. Lerner's new book, The Good Doctor, which touches on issues of patients' rights, autonomy, generational friction, and the remarkable bond between father and son.

Below, Dr. Lerner discusses some of his father's unique stories and what it means to be a "good doctor."

The Lerner Lectureship is generously supported by Sam Miller, a grateful patient of Dr. Phillip Lerner.

Why did you write The Good Doctor?
There are several reasons. First, when someone is a historian of medicine and had a father who kept copious journals about his career as a physician, it is hard not to imagine fashioning this information into a book. Second, including medical school, I have now been in medicine for thirty years. To the degree that I have achieved some wisdom, I figured it was the time to reveal it. Third, my agent, Robert Shepard, has been trying to get me to write a trade book forever. So I finally succeeded. Fourth, and most important, the book is a tribute to my father, who I believe exemplified what it means to be a "good doctor." It is a taller task these days, but one I think that those of us in medicine should try to embrace.

What did you learn about your father from his journals and your other research?
The main "finding" about my dad's career was how he felt it was his duty, having mastered the scientific literature and learned as much as possible about his patients' lives and values, to make the right clinical decisions for them. This made him an unabashed paternalist and someone who, in certain circumstances, was even willing to mislead patients to get them to do the "right thing." As his career progressed, and bioethics and patients' rights emerged, he begrudgingly began to incorporate some of the new dogma about informed consent into his practice. But he remained strongly opposed to the reflexive use of algorithms and the practice of giving patients menus of diagnostic or therapeutic options. He believed that these approaches were not congruent with the true practice of medicine.

What were some of the most interesting stories you discovered?
Well, I guess you could say there were good and bad ones. One of my favorites was the time that my father got an elderly Orthodox Jewish woman to agree to an open lung biopsy by getting one of his infectious diseases buddies, who was a devout Catholic, to do a consultation on the patient. When this doctor took out his rosary to pray for the woman, she could not say no. In another case, my dad not only diagnosed meningococcemia, a severe bacterial blood disease, at a patient's home, but deduced that she had recently been playing tennis by the fact that the rash was worst in the area of her right forearm.
On the flip side, there is the story that starts the book in which my father placed his body over a recently-deceased patient to prevent his colleagues from resuscitating her. As the patient did not have a DNR order, this violated both the legal and ethical standards of the day. He also tried to get doctors and nurses to give both of my extremely-ill grandmothers enough morphine to get them to stop breathing. But even in these instances, my dad was acting according to his fervent beliefs about what it meant to be a compassionate doctor. After preventing the CPR, he wrote that he had acted based on his "30+ years as a physician responsible for caring and relieving the pain of my patients who can't be cured."

What lessons do your dad's and your medical careers reveal for future physicians and health care reform?
I would first point out that there is no going back to the paternalism of my dad's era. Patients' rights are here to stay. Plus, modern doctors do not have the time to practice the intensive, patient-centered care that my father did. But there are ways in our modern system to replicate some of what my dad did and stood for. There is a bit of a backlash against patient autonomy, for example. Patients may be quite willing to take advice from physicians that they know and trust, even about end-of-life issues. And although office visits may be only 15-20 minutes, it is still possible to spend a few minutes discussing what is going on in a patient's life. I like to write down what we discuss in my notes and bring it up at the next visit. And the doctor-patient relationship does not only have to occur via face-to-face encounters. Innovative programs are using phone calls, Skyping and e-mailing to allow busy physicians to stay in better touch with their patients.

Visualizing Empathy: An interview with Laura Ferguson

April 14th, 2014

Artist Laura Ferguson developed a lifelong passion for drawing the body, both inside and out, as a child when she was bedridden with scoliosis. Five years ago she created an Art and Anatomy seminar in the Masters Scholars program, as part of an artist residency at NYU SOM.

The class, which includes medical students, faculty and staff, meets in the cadaver lab where gross anatomy is taught. Once transposed into an art studio, the setting provides students with a chance to engage with the dissection experience more creatively than in gross anatomy, where the focus is on learning the parts of the body and what happens during the disease process. The simple act of drawing, Ms. Ferguson says, encourages a more intimate involvement with the beauty, complexity, mortality, and visceral reality of the human body.

"These artists are imagining the living body as they draw: looking at bones and cadavers but imagining the person who once inhabited them - and also imagining the living, moving anatomy within themselves."
"There is an inherent humanism in art, and a great power to communicate - to express things that can't be as easily communicated in other ways. Art allows us to share experiences that go deep into the human spirit and psyche - the same places where illness or pain or differentness or isolation often take us."

Ms. Ferguson brings her experience as a patient into the studio to encourage students to explore individual differences among body types. While she recognizes that students need to memorize organs, tissues, and nerves in order to become competent physicians, she stresses the importance of recognizing that variations in body types do not define the person nor the illness they may have at any given time.

This year, Ms. Ferguson organized an exhibit of "Art & Anatomy: Drawings" in the MSB Gallery at NYU Langone Medical Center, featuring 76 artworks made in the class. Ms. Ferguson said she was struck by the audience's powerful reaction to the exhibit-for some there was an inherent discomfort, even fear, connected with seeing the inner body, but that became a shared sense of wonder for the viewers as they recognized the transformation of anatomy into art.

At the opening of the exhibit, Hannah Bernstein, one of the student artists, had this to say:

"When I created drawings for the course I tried to capture this appreciation for the beauty and variation of the human body. I learned to appreciate things that aren't conventionally beautiful, like the curves of the femur and the intricate network of blood vessels covering the heart. I also learned that in general, real people don't look like textbook illustrations. No two people are the same, and no one is 'perfect.' Each body has its own unique deviations, and this applies to what's inside as much as what's on the surface. This is an important lesson for any future doctor, and I'm grateful that I got to learn it from such a unique perspective."

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More on Art and Anatomy

•On April 30th, a slideshow of "Art & Anatomy: Drawings" will be screened as part of "Reading the Body: Live!"! - a literary evening honoring Frank Netter, with stage actors reading poetry and prose about the body from the Bellevue Literary Review.
•A gallery of images from the show can be viewed online at http://school.med.nyu.edu/humanisticmed.
•A short film about Laura Ferguson and Art & Anatomy was recently featured as one of its "untold stories" by Narrative,ly (http://narrative.ly/art-in-strange-places/how-to-draw-a-human-heart/).

The Social Construction of Cancer - Part 3

November 27th, 2012

Editor's Note: This is the third of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU’s department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport.

Part III

In a later visit with the homecare teams, I met Rajesh - a 29-year-old man who has been battling cancer since his teenage years. The walls of his room in a dense middle-class neighborhood were bare but for two pictures - one of a Hindu deity and another of his parents who had passed away in an accident when he was still young. Rajesh had contracted cancer while working in a chemical factory in his late teens. The cost of his treatment led him to lose the little property that his parents had left him when they had died. The relatives that he lived with now took him in, but refused to extend any form of empathy or care. The stigma of the diagnosis of 'cancer' along with fears of its communicability saw to his isolation in the small verandah of the house. Yet, Rajesh's will to live was strong; on his own, he would travel to the All India Institute for Medical Sciences (AIIMS) early in the morning, negotiate the intricacies of the bureaucratic processes and make himself available for treatment.

As it stands, effective public health insurance is by and large absent in the Indian health scenario. In its place, the only financial respite for the poor comes in the form of subsidized treatment at government facilities. The bureaucratic procedures involved in procuring these government grants are daunting at best; very few cancer patients are able to transact the opaque bureaucratic process within the time allowed by rapidly progressive malignancies. Fortunately in Rajesh's case, where kinship had failed, a local network of knowledge and care stepped in. Cansupport and a sympathetic AIIMS doctor collaborated together to procure both a part-time nurse to care for Rajesh, while also taking him through the process of applying for a set of government grants.

In my conversations with Rajesh, it became clear that the years battling both the disease and the public health system and spent him. Time and again, his upbeat demeanor would collapse; at the end of one of our conversations as I made to leave, he stated baldly that if the disease returned he would not fight it again. It had deprived him of years of income and left him at the mercy of a family that had not cared for him at his most vulnerable. He had become the errand boy of the locality, earning his room's monthly rent by doing chores for his family and neighbors. His resentment towards his family was something that he had been forced to learn to hide; working for them allowed him to transact the complicated business of 'living on' with the disease. Over the next few weeks, Cansupport would try and work with its funders to set Rajesh up with a food-cart, to gain him the monetary security and independence he needed. While the biology of the disease was now in remission, the collapse of the infectious life of cancer had spread outside the body, jeopardizing his will and ability to carry on.

Dwaipayan Banerjee is a doctoral candidate at the department of social anthropology at New York University. Prior to his doctoral candidacy at NYU, he graduated with an M.A. and an M.Phil in sociology from the Delhi School of Economics, India. He has recently completed ethnographic work concerning the experience of cancer, pain and end-of-life care in India. His research follows the circulations of these experiences across different registers - language, medicine, law and politics. His broader interests includes working at the intersection of philosophy and anthropology, as well producing and studying ethnographic film and media.

The Social Construction of Cancer - Part 2

November 14th, 2012

Editor’s Note: This is the second of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU's department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport.

Part II

However, at this point, Shambu and Rohini's story took a sharp turn. The palliative care team I was visiting with discovered that, partly because of not collectively acknowledging the extent of the disease, Shambu and Rohini had started visiting a new neighborhood private 'ayurvedic hospital.' This hospital claimed to be able to completely cure cancer, provided that the patients pay whatever was the breaking limit of their financial ability. Perfectly aware that it was not her place to recommend or dissuade a line of treatment, the counselor restrained her own opinions. As the family talked, it became clear that to avail this therapy, they were considering risking their son's future as well as their ability to remain in their home. Shambu had been the sole breadwinner in the family, and given the imminent possibility of his passing, such decisions could have catastrophic consequences. The counselor still remained non-committal on the viability of this promise of cure, but skillfully urged Shambu and his wife to talk and think through what they were doing.

Soon, as they talked about their options for the first time, Shambu and Rohini started complaining bitterly about the treatment they had received at this hospital. The self-purported physician had refused to come into contact with the patient, or even take a medical history. Instead, their conversation had revolved around the staff ascertaining what the family could afford. (The counselor was to later tell me that many such 'alternative' hospitals had sprung up around lower-income neighborhoods, and for the urban poor at the margins of an overcrowded public health system, these were unsurprisingly seductive lures.) Soon afterwards, Shambu began to narrate his own life, telling the story of how he had planned his own insurance policies based on an astrological prediction that he would contract cancer, but how that prediction had fallen short by two years and wrecked havoc with his plans.

To my surprise, I began to see how the counselor's decision to listen patiently had allowed the space for these narratives to develop, and how the family now began the slow process of coming to terms with the prognosis. This would certainly not be the last word on the matter, but the team's skilful handling of the sensitive ways in which illness knowledge circulates ensured two vital things. On the one hand, they were careful not to heavy-handedly tear the web of careful ruses that continued to bolster the family and the relations between them and the social worlds around them. But at the same time, they laid the groundwork so that these partial denials would not financially ruin the family in the near future. Thus, the team facilitated the process through which Shambu and Rohini could place the illness within a comprehensible narrative of their lives, while beginning to prepare for what was to come.

Dwaipayan Banerjee is a doctoral candidate at the department of social anthropology at New York University. Prior to his doctoral candidacy at NYU, he graduated with an M.A. and an M.Phil in sociology from the Delhi School of Economics, India. He has recently completed ethnographic work concerning the experience of cancer, pain and end-of-life care in India. His research follows the circulations of these experiences across different registers - language, medicine, law and politics. His broader interests includes working at the intersection of philosophy and anthropology, as well producing and studying ethnographic film and media.

The Social Constructions of Cancer

November 2nd, 2012

Editor’s Note: This is the first of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU’s department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport.

Introduction

The contemporary landscape of healthcare in Delhi inspires very little confidence. The lack of public insurance, scarcity of resources and rising cost of care in the vast network of private hospitals has ensured that for much of the city's poor, the diagnosis of cancer comes without any hope of treatment. Even at the best public health institutions, waiting lines for chemotherapy extend for months, compounded by the fact that over 80% of patients present at incurable stages. In the four-part entry that follows, I show that palliative care -far beyond its commonplace association with comfort at the end of life - is an urgent, irreplaceable and imaginative intervention that seeks to both diagnose and treat the social costs of the disease amongst the urban poor in India. I show that in its understanding of the form of the worlds that both collapse around and emerge through the disease, palliative care is really the condition and prerequisite of therapy, rather than its failure.

The anecdotes here come from a year of ethnographic fieldwork following intensive care, public health and oncology in India. Specifically, I describe some of my experiences working with and studying Cansupport, a pioneering palliative care organization in Delhi that provides home-based psychological and physical support to lower-income advanced stage cancer patients.

Part I

One of the first things that came to light when exploring cancer care in India was that knowledge of the prognosis was an extremely convoluted matter. From my first days in working with home-care teams, I was told to never mention the word 'cancer': the understanding was that patients hardly ever 'know' that they have the disease. Needless to say, this came as quite a surprise. Later on, analyzing the intake forms of about 2000 patients while working as a consultant at India's largest public hospital, I realized that about 85% of cancer patients were indeed recorded as 'not aware' of either their diagnosis or their prognosis. Delving into the emergent literature on 'psycho-oncology' in India, I began to realize this was a well-recognized problem within the emergent discipline. But it took several weeks of ethnographic work in the homes and neighborhoods of patients before the meaning of "awareness" and "denial became clearer to me.

In one of the early days of the Delhi winter, I accompanied a team on a visit to the far eastern borders of the region. We were greeted by the patient's wife - Rohini - and taken inside a room with two beds. On one lay Shambu, a former life-insurance salesman who presented with an advanced stage of the disease. In a pattern that often repeated itself, once Shambu's initial physical discomfort was taken care of, the counselor turned her attention to the question of the family's 'awareness' of the diagnosis. It was during interactions such as these that I realized the stakes of 'knowledge' around cancer. First, in a public health system in which oncologists see over a hundred patients in the space of a few hours, the communication of a diagnosis and prognosis - often across barriers of class and language - is often a half-achieved ideal at best. Second, even if a sense of the diagnosis is communicated and therapies undertaken, I realized that beyond the space of the hospital, just the hint of the word 'cancer' has the powerful potential to ostracize the patient from social life. Landlords would evict cancer-marked families, neighbors would suspend social interaction, marriages in the family would be jeopardized, and cremators would refuse the body.

Shambu and Rohini's case captured this double elision. The counselor's tactful conversation with Rohini elicited that she had a hazy but more-or-less accurate picture of the bleak prognosis, but that Shambu himself had not been explicitly 'told'. A separate conversation with Shambu revealed that he too was not as much in the dark as Rohini imagined. In a situation that recurred almost inevitably, both partners had tried to keep each other in the dark, firm in their conviction that putting the diagnosis into words would collapse the world of their loved one. They each recognized not only the power of the diagnosis to inflict psychic harm on the self of the patient, but also the threat of being marginalized and isolated from their extended family, their neighborhood and their friends. The world they had built around cancer, a world they had lived in for almost two years, had no place for its acknowledgement in language. To label this complicated work of living together as living in ignorance or denial would do it a great disservice. The work of home-care that took shape recognized this and often pulled back from pushing the disease blindly onto the surface of words.

Dwaipayan Banerjee is a doctoral candidate at the department of social anthropology at New York University. Prior to his doctoral candidacy at NYU, he graduated with an M.A. and an M.Phil in sociology from the Delhi School of Economics, India. He has recently completed ethnographic work concerning the experience of cancer, pain and end-of-life care in India. His research follows the circulations of these experiences across different registers - language, medicine, law and politics. His broader interests includes working at the intersection of philosophy and anthropology, as well producing and studying ethnographic film and media.

Island Time

August 15th, 2012


As one might expect, much of medical training occurs in the inpatient setting. Teaching hospitals, brimming with an elaborate hierarchy of trainees and supervisors, offer a critical mass of patients and pathology. Typically these patients present with exceptionally complex histories and comorbidities enriching the substrate of the teaching environment. Counter-intuitively, most doctors do not work in inpatient settings. This is especially true for psychiatry wherein the great majority of practitioners work in the outpatient setting, practicing various forms of psychotherapy.

Unlike in other fields of medicine, residents in psychiatry experience virtually no outpatient psychiatry until their third year (PGY-3). Most psychiatry residents therefore spend a minimum of six years of training before they venture beyond the frontier of outpatient psychiatry, into a wilderness they will eventually call home. For many, this is the moment they have been waiting for since deciding to become a doctor: their first therapy session.

Angst is perhaps the most suitable name for the escalating feeling leading to that first 45-minute office visit. Beyond simple anxiety or worry, there are existential elements implicating one's life, career, and purpose in the world. Additionally, there is both hope and dread- hope that salvation will eventually come (the patient will get better), and dread that you will be unable to bring it. Unlike the inpatient setting, befit with teams of providers embedded in elaborate systems of care (however under-funded and uncoordinated), the outpatient office can be a shockingly lonely venue, a small island where you sit naked waiting to be eaten by a large animal.

From one perspective, there is not much difference between a typical 20-30 minute encounter or "therapy session" on an inpatient unit and a 45-minute office based session. Yet there is an irrational pressure put upon oneself to make the most of an outpatient visit and a simultaneous intense fear that 45 minutes will be way too long (never in the hospital does one have time to worry about running out of things to say). Undoubtedly connected to the well-intentioned (and yet grandiose) identity as healer, this pressure suggests you alone will be in charge of saving your patient's life. Adding to this self-conscious uncertainty is the loss of anonymity afforded to inpatient providers. No longer able to hide behind the tribal masks and dress of the hospital ward treatment team, one's nakedness is more viewable in the outpatient setting.

Most concerning is the realization that, unlike inpatients who often draw from a more familiar cast of acutely ill characters (the demented elderly woman who screams all night after a recent infection, the manic psychotic young man from another state off his meds, the chronically homeless schizophrenic with a recent decompensation…), outpatients can come from anywhere. Fresh off the inpatient unit, I remember once thinking in early July, "Who is this stranger?" I was sitting opposed to a fashionably-dressed middle-aged man on a single antidepressant discussing his upcoming trips for business and summer vacations. Several years since a recent major depressive episode and suicide attempt, it was as though we sat chatting, comfortable by a campfire, the specter of his disease far from our minds.

It wasn't until I returned to the hospital that I appreciated the outpatient setting for what it truly is. Amidst the reverse culture shock of a long call night in the emergency room, I found myself between three newly admitted and screaming patients; one in withdrawal begging for more benzos, another acutely manic and irritable, the third demanding discharge despite a near-lethal overdose just hours afore. I missed my verdant, tranquil island.

It was at this point that I could look back at the thick, threatening, overgrown paths I had traversed and appreciate the open air of my surroundings. It was a few weeks later until I realized who else had been through those woods, lived even deeper in the dark recesses of the forest.

Now sitting in my office I strategize with patients on how to maximize their island time. I wonder how to keep the campfire burning so that we may "talk" as long as possible. And most importantly I try to mentally prepare for the day when a patient must return to those deep dark woods and how I can best make that journey with them.

-Arthur Robinson Williams

Arthur Robinson Williams is a PGY-3 Resident in the Department of Psychiatry at New York University specializing in addiction psychiatry, ethics, and research. He earned his M.D. and a Master in Bioethics at the Perelman School of Medicine at the University of Pennsylvania and the Penn Center for Bioethics.

The Artist in the Anatomy Lab

June 26th, 2012

Laura Ferguson came to the NYU School of Medicine as artist in residence in 2008 and currently has an exhibit of her artwork in the MSB Gallery at NYU - Langone. In a previous blog post, Ms. Ferguson discussed how she uses medical imagery in her work. In speaking with her by phone in the days following the opening of the current exhibit, I asked her to discuss her work with medical students who study anatomical drawing with her during an eight session elective, 'Art & Anatomy,' in NYU's Master Scholars Medical Humanism Program.

In her work with students (as well as faculty and staff) Ms. Ferguson sees herself as a mediator between the world of art and medicine and between doctors and patients. Excerpted below is some of our conversation.

-Lucy Bruell, Editor-in-Chief, Literature, Arts, and Medicine Database

I came to NYUSOM with the idea that an artist’s perspective could be of value to the medical school community. This exhibit is a chance for me to show what I’ve been doing as an artist in the four years that I’ve been here. I've learned so much in my interactions with faculty, staff, and students. This is a chance for me to give back and to share what I’ve been doing, which was part of my original goal. My work with students has been a big part of that.

When I first came in, the first year, the students would study gross anatomy the first semester of medical school, and those who wanted to took my class in the spring semester. In other words, they’d have dissection in the fall, and then drawing in the spring. But after that, the curriculum started changing, and now they have gross anatomy spaced out over 18 months. And they may take my class whenever they want to, because it’s given every spring and fall semester, so they may be at different stages in learning anatomy. Some of them may even take my class before starting gross anatomy, so I become the person who introduces them to the lab, which I wasn’t expecting. But I've always thought that drawing is a great way to learn.

I basically learned anatomy through drawing. You spend so much time communing with the object or the thing that you’re drawing that you come to know it in a way that’s much deeper than dissecting it or just looking at it in a book. It’s a very different relationship to being with the cadaver, or the bone. Drawing in the anatomy lab is much more open ended; it’s just about the process of learning and drawing. You don’t have to memorize anything, or have a test afterwards, so it’s very relaxed, freer. There’s also a mindfulness that you get into when you’re drawing, that I thought would also be a good experience for doctors-to-be, just to have a different connection to the bodies. Another aspect is the idea of individuality, which is an important part of gross anatomy. The fact that there are all these different cadavers, all these different people, and each one is different from the others. The students get to look at different ones and see all these anomalous things. But when they’re looking at the anomalous things, it’s largely to see pathologies, or things that are wrong. Obviously they need to learn that sort of stuff, but my approach, especially as someone with scoliosis, is more to just appreciate the individuality; that we’re all different inside, just as we’re all different on the outside.



The class is held in the anatomy lab. When you enter, there’s a study room in the middle, with just tables. You don’t see any cadavers when you first look in. And then on the two sides there are two rooms that have all the cadavers. We first meet in that middle room, and I start them off with drawing bones. Next, I give them a tour of the cadavers, especially for the ones that haven’t been in the lab before, and when they’re ready, I let them start drawing in there. Sometimes we actually take out a heart or a lung from the cadavers on a tray, and they draw it. It can be a little tricky, because we have to depend on what stage the students are at in dissecting: when they've just begun, there's not much to look at or draw, and when they're almost done, the cadavers may be hard to look at. But we manage to find something to draw at all these different stages.




In the beginning, I tried to get the students to talk about the emotional side of being in the anatomy lab. Some did, but others were resistant, and would just say "We’re fine. After the first day we got used to it." Which is probably true on one level, but on another level, there has to be a lot going on - it’s such a profound experience. But when you’re drawing, you’re expressing yourself, whether you like it or not. Something’s coming out of you - especially if you’re drawing from a cadaver or a part of one. You’re bound to be, on some level, dealing with feelings. To let it happen, in an open, non-judgmental environment, has an effect. And students do talk to me at different times about the deeper issues of being in the anatomy lab, how they deal with that in different ways…

The biggest problem for students is time, so the class is a treasured thing. They can’t always make it to every session. But the ones who do come, I think it means a lot to them. I’ve been very amazed and interested to find how many of the students actually have some sort of arts background, or humanities background, and for them it’s a link to a whole other side of themselves that they may feel they have to put aside in medical school. So it can be very meaningful - their drawings are something they can show to their friends and family- they can make that connection to the other side of their interests that they had before they started medical school.

Laura Ferguson's exhibit will be on display until August 13th. An exhibit of student work is scheduled for November.



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