Reflections of a Young Doctor

August 3, 2015 at 10:32 am

From the Division of Medical Humanities Newsletter:

Does asking medical residents to participate in reflective writing exercises help them to better connect with patients? New York magazine highlights a study, recently published in The Journal of Health Communication, that addresses this question. Excerpts from the program exercises are featured.

continue reading at nymag.com

Oliver Sacks - "My Periodic Table"

July 31, 2015 at 10:18 am

From the Division of Medical Humanities Newsletter:

A moving essay from the great Oliver Sacks serves as a primer for embracing life, and science, even as the end approaches: "And now, at this juncture, when death is no longer an abstract concept, but a presence — an all-too-close, not-to-be-denied presence — I am again surrounding myself, as I did when I was a boy, with metals and minerals, little emblems of eternity."

continue reading at nytimes.com

Wherever You Go: Self-Representation and Williams Syndrome

July 14, 2015 at 5:04 pm

Jess Libow is currently a summer intern at the Bellevue Literary Review. She is a rising senior English major at Haverford College interested in disability studies.

Nader and Josh at the Wildhorse

All photos courtesy of camp staff

Looking out over the dance floor at Nashville's Wildhorse Saloon as other members of our group line danced with the crowd below, Mark told me "It's good for us to get out into the community so that people know we exist." As a counselor this past June at Lifting Lives Music Camp at Vanderbilt University, run by the Academy of Country Music, I lived in a dorm with Mark, who is 51, and seven other men with Williams Syndrome. After this experience, I couldn't agree with him more.

Lifting Lives is a weeklong musical experience for people ages 16 and older with Williams Syndrome. Over the course of the week, campers from all over the country come together to write a song with renowned Nashville songwriters and, after much rehearsal, record and perform their original work at the historic Grand Ole Opry.

Recording Studio

While performing a song written only a few days earlier at the Opry might be intimidating to most, many people with Williams Syndrome thrive in this sort of setting. Williams Syndrome (WS) is a congenital neurodevelopmental disorder caused by the deletion of 26 genes on chromosome 7. WS is an extremely rare condition: the NIH estimates it occurs in 1 in 7,500 to 10,000 live births. In addition to mild to moderate intellectual disability and a range of medical issues, including cardiac conditions, people with WS are likely to have a number of distinct social qualities. Studies have shown, for instance, that people with WS have a strong predilection for music. People with WS also tend to have remarkably little social inhibition; they are eager to meet and please others and are deeply attuned to the emotional states of those around them. Their profound desire to connect lends itself easily to musical performance - people with WS are natural storytellers.

As an English major interested in disability studies, I was drawn to Lifting Lives because I saw it as an opportunity to witness people with disabilities telling their stories through songwriting. This year, the campers wrote a song with Ross Copperman and Heather Morgan titled "Wherever You Go." It's an uplifting song about aspirations and supporting one another. The most notable part of the song is the bridge, which is both universal and incredibly specific to people with WS. "Thunder roars and the rain might fall," the song goes, "but together we're unstoppable." This brief moment in the song addresses two significant characteristics of WS. People with WS have extremely high levels of anxiety, particularly about events beyond their control. Thunderstorms are a common stressor for a number of the Lifting Lives campers, and were a constant topic of discussion throughout the week. Because of the extent to which the "roar" of thunder produces anxiety in people with WS, when the campers sing this line many of them are essentially referring to their highest possible level of emotional discomfort - it is both a metaphor and a reality. The second half of the line, "but together we're unstoppable," speaks directly to the value people with WS place on human connection. The lyrics suggest that through interdependence, the campers are able to to withstand anxieties and other obstacles. This celebration of community support not only resonates personally with the campers, but is applicable across differences and abilities.

lifting lives camp

Songwriting and singing provide a creative and exciting way for the campers to tell their stories. David, for example, told me that he'd "always wanted to write a book about Williams Syndrome," but after a songwriting workshop with songwriter Odie Blackmon, "might have to change it up. There should be a song about this!" Like David, however, many of the campers have a propensity for self-representation off-stage as well.

I was struck by the ease with which campers would share stories from their past and especially intrigued by how many of their stories had to do with Williams Syndrome directly. The ever-enthusiastic Gary told me over dinner that he once encountered two nurses in the ER who'd "never met anybody who had Williams Syndrome! And they said what in the world is that? And I said to look it up, 'cause it's a really cool thing to know about!" Trevor, who works with People First, a disability advocacy organization in his home state of Washington, added that "people judge us sometimes, but they just don't know. We're friendly."

Their stories weren't always so straightforward. Some of the campers readily used simile to represent their experiences. For instance, while waiting at the gate to board his flight home, Trevor told me how he felt about my accompanying him. "It's like Barack Obama," he explained, "he’s the most powerful man in the world, but the legislative branch still sometimes helps him. So you're helping me right now." For Trevor, having a counselor wait with him at the airport wasn't insulting; it was merely part of a system of interdependence not unlike one of checks and balances. Similarly, Mark, who loves doing impressions, drew on his love of old movies to teach me about his past. "I identified with Frankenstein’s monster when I was younger," he shared after an impromptu impression of the character, "the neighbors weren’t very nice to me because I had this disability. But I found a way and I made friends."

It's hard not to wonder what drives this impulse to self-narrate. When does the desire to share one's story stop being a symptom and start being political? Does this distinction even matter?

Self-representation is a crucial aspect of disability politics today. As self-advocates, people with disabilities around the world are making sure their voices are heard. As the critical field of disability studies indicates, self-representation is a crucial aspect of advocacy efforts. This kind of political action embraces something that comes naturally to so many people with Williams Syndrome: telling your story. And a lot of the people I met at camp know that this matters. Echoing Mark's sentiment at the Wildhorse, many of the campers want others to "know [they] exist." Like David, who wanted to write a book, or maybe a song, about WS. And Kurt, who has a radio show every week. Josh, who told me he plans to write a blog for the Williams Syndrome Association. And Trevor and Dara, who are both self-advocates in their hometowns.

In my experience, people with WS challenge how we think about narrative and storytelling. They force us to reconsider what motivates us to share, to speak up, and to put ourselves and our stories out there. Biology and politics both come into play. It can be tempting to write off someone's unsolicited story as a symptom of their disability. It can also be tempting to romanticize their efforts to speak up for themselves with an overzealous "good for you" and a pat on the back. But at the end of the day, there's something powerful about someone sharing their life experience and perspective. The people I met at camp, whose stories I've tried to recount here, want to put everything on the table. I think they might be onto something.

To learn more about Williams Syndrome, please visit https://williams-syndrome.org/
To learn more about Lifting Lives, please visit their website

Cortney Davis - When the Nurse Becomes a Patient: A Story in Words and Images (Part II)

June 9, 2015 at 2:00 pm

(Kent State University Press, 2015)

[Editor's Note: This is Part II of a dialogue between author and painter Cortney Davis and our Art Editor Laura Ferguson. Part I can be read here.]

Laura: I'd love to know more about your studio process. I see that some of the pieces are acrylic, some oil, and some include collage. Are they as unselfconscious as they seem? Did they come into being easily and quickly, without a lot of working over - or did you just make it seem that way? You let us feel your pain and your aloneness, you invite us to understand, and you allow us in to your experience. I suspect that may be in part because your paintings are not too perfect and polished.

Cortney: The paintings were painted very rapidly with no working over. I was discharged in mid-July, and the first painting was done at the end of July. Most of the paintings were done in August, six of them, one after the other, usually only a few hours per painting, or less. Three were done in September and two in October. I actually didn’t know what I was doing, technique wise. I painted in my basement in front of an open sliding door, with music playing (most often "The Tallis Scholars Sing Thomas Tallis" or "Agnus Dei, Music of Inner Harmony"). Painting also took my mind off my body (I was having a lot of medication side effects) and I really felt blessed to be alive, to be home, and to be standing by the open door with summer all around me, doing something that seemed totally free from "thought." When I finished the last painting, I looked at them and wondered exactly how they came about. It seemed there was no "planning" to them, just the painting.

As I recovered, however, by October I could sense the paintings becoming more "thought about" and less unselfconscious. I began to wonder if I was painting "correctly" and I found myself being more careful, more precise with the last two paintings. It was as if when I regained control of my body and my illness was less central, less in command of my day, I also moved, little by little, away from the totally un-thought-about and un-planned-expression that marked the paintings. (The paintings in the book, by the way, are not in the order I painted them - they have been arranged, in the book, in a chronological order to tell the story. I painted the images without rhyme or reason, just painting whatever seemed most urgent.)

The commentaries were added in November and December, at a time when words seemed to return to me, certainly the creative medium in which I was most comfortable and felt most proficient.

The Dark Night

Laura: You say that "painting seemed to be all about the body" but also that "painting took my mind off my body." Is that a contradiction? Did it feel like getting back to your body the way it felt before the illness?

Cortney: Painting felt physical, messy. It felt more like my body if my body only consisted of the senses.

When I painted the last one (which is the last in the book, "Angel Band") I noticed it was very neat - it felt less messy than the earlier ones - and I knew it was a sign that my head was taking over again. I haven't really done any more painting since then.

Laura: I wonder if being so vulnerable and out of control, and in a situation that forces us to live in our bodies in a very basic sense, opens us up, frees up that kind of expressiveness. The side of ourselves that needs to get things right becomes unimportant.

I'm thinking about the med students in my Art & Anatomy drawing class. I find myself trying to get them to loosen up, to enjoy being messy, to let go of trying to get it "right" - which is hard, because it's so important in every other aspect of med school. I think this is related to the issue of control that you bring up. You speculate that "maybe turning illness into something creative is a way of taking control," and I think that's true. It allows us to organize the experience, to present it as we see it. But paradoxically, it's a control that comes from letting go of control. As you say, it works best when it's messy and just comes out, without a lot of thought or oversight from one's internal editor.

This tells me that there's the potential for tremendous creativity in the world of medicine, from both patients and caregivers - and that art is a great way for each to communicate and open up the reality of their experience to the other.

Cortney Davis - When the Nurse Becomes a Patient: A Story in Words and Images

June 2, 2015 at 9:40 am

(Kent State University Press, 2015)

A dialogue with Art Editor Laura Ferguson (Part I)

Carol Donley, in her annotation of Cortney's book in the LitMed Database, writes that "the vivid paintings speak for themselves, and they add a different way of knowing not available through words." As an artist whose work explores the experiences of her own body, I believe strongly in the power of art to express things that can't be as easily communicated in other ways, especially about experiences that go deep, like illness, pain, and isolation. Because Cortney is both a medical professional and a wonderful writer, I welcomed the opportunity for a dialogue with her about the expressive power of visual art.

Laura: You chose painting to express your feelings about the experience of being a patient, even though you are also a writer and poet. Can you say more about why it felt more right to express yourself without words? Do you think it was because the experience was so physical, so much about the body? For me, drawing seems to come directly from my body - it allows my body to express itself directly, through my hand. Is that how it felt for you?

Cortney: I didn’t really choose painting, rather it sort of chose me. When I was finally discharged after the second hospitalization my friends wondered if I was going to write about my experience. I felt the need to respond to my illness in some creative way (maybe turning illness into something creative is a way of taking control?), but I really could not find the words. It felt as if there were no words to adequately express what I had been through or what I’d experienced in the hospital. Words seemed too intellectual, too distant and too controlled to express something that felt raw, profound, and frightening. Also, since I’m primarily a writer, there is always an internal editor that watches over my shoulder when I write, and I didn’t have the emotional energy to embark on a writing "project" that I’d be trying to make "good" or "worthy."

My urge to paint took me a bit by surprise because I’m not a painter. A few months before my surgery, a painter friend had invited me to her house to paint with her, and she had introduced me to acrylics and oils - that was the first time I’d put paint to canvas. But after a few of our painting sessions, I was hospitalized. When I was discharged, I remembered that I had paints and some blank canvases at home. I felt drawn to paint images that I recalled from my hospitalization. My illness was all about my body, and painting seemed to be all about the body too: the smell of the paint and the feel of the paint and the brush on the canvas, the movement of my hand and arm, the lack of an internal editor (since I really had no idea if I was doing the painting "right" or not), the emotional impact of the colors and shapes, and the lack of the need to "intellectualize" the process.

CortneyDavis-Dilaudid-Land-72

Laura: Why did you then decide to add words? How would you characterize the relationship of your words to your paintings, or what you felt their purpose was? Do you think the paintings can stand alone?

Cortney: After I’d painted the twelve images, I wanted to share them with some of my nurse friends and with my family. I took photos of the paintings with my iPad and wanted to send them around, but I knew that viewing the paintings alone, unless someone knew a bit about what had happened, might be confusing. I added the commentaries in an attempt to make my very personal experience more universal, and to put down in words why those particular images stayed with me. By the time I added the commentaries, I was months into my recovery and feeling as if I might now find the words. The painting had helped me enter once again into the illness in an attempt to make emotional sense of it, and maybe the words helped make intellectual sense of it.

I now think the paintings could stand alone (now that I can see them more objectively), or at least a viewer might get a general sense of the story if he or she viewed the images as a series. But, since I’m a writer and not an artist, I felt the urge, eventually, to explain to others and to myself just what was going on in each painting.

Laura: Would you say that you made the paintings more for yourself or for other viewers? Do other paintings convey powerful, deep feelings to you? Do you think the paintings allow viewers to empathize with your experience?

Cortney: I think some artists and writers "do" their art in spite of illness, and some because of illness. In my writing about being a nurse, I write because of others’ illnesses as an observer. But painting as a patient, I was painting and then writing because of my own illness. Interesting! I never would have come up with those specific images if I’d not been a patient.

Laura: You told me that some people were "creeped out" by your paintings, or found them too depressing. - but I don't think people who've been there, who've been through experiences like this, will find them depressing. I think it's great that you go right to the heart of suffering, not sugar-coating it. You're willing to admit how out of control, how vulnerable you felt - and I think that totally comes across in the paintings. I'm sure you were an empathetic nurse, so can you say more about why you needed to experience being a patient yourself in order to understand what it was like to feel that vulnerable?

Cortney: I had been a patient many times before this last illness. But I’d never been close to death as a patient, or so sick for an extended period of time. I believe it might have been the very real possibility that I could die that made a difference in my understanding of the power of illness. I experienced a deep hopelessness and even a wish that I would die quickly, if I was meant to die. I had time to contemplate suffering and to review my life, realizing all the ways in which, while I’d been empathic, I had failed to understand the depths of suffering - mental, physical and spiritual - that gravely ill patients can experience.

In addition, my prolonged hospitalization was the direct result of a surgical mishap and, during my hospitalization, there were other complications that stemmed from lab and medication errors. Not only was I seriously ill, I was for the first time a patient who was unable to rely completely on those who were caring for me. Because I was a nurse, I could see the events and complications of my illness both from the inside - my personal experience of them - and from the outside - my inability to make sense of why or how these errors had occurred and were occurring.

As a writer, I’d always thought that I had the vocabulary with which to express what my patients might be experiencing, and to express what I was experiencing as their caregiver, in my poems and non-fiction. But during this illness, I felt in a very profound way the metaphorical inadequacy or incompleteness of my vocabulary. There is a level of vulnerability that can’t be intuited from the bedside but can only be experienced.

Laura: Related to that, do you think it's possible that nurses (and other medical professionals) get a sense of control from their jobs, that makes them feel protected from being in the patient role - a kind of magical thinking?

Cortney: I believe that all caregivers are acutely aware, especially after years of practice, that it only takes one second for someone to be thrust from the role of caregiver to the role of patient. And I believe too that there are many instances in medicine and nursing in which caregivers feel totally out of control - not wise enough, not quick enough, not prepared enough. I never felt that I would be "in control" by virtue of being a nurse, or that being a nurse combated any fear of dependency. I was more often in awe, feeling great vulnerability, but always both enriched and humbled by my interactions with patients.

[Editor's note: Part 2 of this dialogue will be published next week, with more about Cortney's studio process, and thoughts about artmaking as a way of both holding on to and letting go of control.]

Thinking About the Body Through Visual Art

March 16, 2015 at 1:58 pm

Readers of the Literature, Art & Medicine Blog may remember me as the first Artist in Residence at NYUSOM, or as the creator and teacher of Art & Anatomy in the Master Scholars Program in Humanistic Medicine [previously] [interview]. You may have seen my own or my students' work on exhibit in the MSB (Medical Science Building) Gallery at NYU Langone Medical Center, or read Founding Editor Felice Aull's insightful annotation of my work in the Database. Coming to the world of medicine as an artist, patient, and inhabiter of an unusual anatomy, I've been honored to have a voice in the humanistic medicine dialogue. Today I'm writing to introduce myself in a new role that I'm excited to take on, as the new Art Editor of the revamped, redesigned LitMed Database and Blog.

My first task as art editor was to find an image to represent Visual Art on the website's new landing page. It was a challenge, but a fascinating one … and in the end I was happy to find the solution not in one perfect image but in bringing together this set of four. They represent an intriguing spectrum of cultures, time periods, media, and ways of thinking about the body, each gaining a deeper resonance by being juxtaposed with the others.

Litmed-lpage-VisualArt
left to right: Laura Ferguson, Pavel Tchelitchew, Sopheap Pich, Leonardo da Vinci
more information and links to each image can be found at [http://medhum.med.nyu.edu/about]

In each of these artworks, an image of the head or the brain is imbued with a sense of consciousness, an awareness of its own embodiment. Each of the artists is attuned to correspondences between the forms of nature and those of the body. With varying degrees of transparency, they each allow us to see or sense the underlying anatomy - and more broadly, to look beneath the surface of life, which is what art is able to do so well.

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. The connection between artist and viewer 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.

Leonardo_blogpost

Art looks beneath the surface of life - but strangely enough, it rarely looks beneath the surface of the skin. For Leonardo da Vinci, drawing anatomy was an essential part of his artistic investigations into the nature of human experience. The anatomical studies in his notebooks were drawn (c.1509-10) from personal observation of human dissections - but also from life models. His drawings take us beneath the skin of real people who still come alive to us 500 years later, and make us think about the beauty and complexity that lies within our living bodies.

Surprisingly, since Leonardo's time very few artists have looked inward to show us the beauty of our intriguing, spatially complex inner landscapes, or to explore their meaning. Anatomy became part of a genre, medical illustration - which has given us many great images but, as it grew more scientifically accurate over the centuries, became increasingly generic and impersonal. Now when we try to visualize our unique inner spaces, we tend to imagine something that looks like a medical textbook. It's hard to find images we can relate to - especially for those of us (like me) with unusual anatomies.

Tchelitchew_blogpost-r

One of the few artists to use the imagery of anatomy was Pavel Tchelitchew, who painted Interior Landscape (above left) and The Golden Leaf (right) in the 1940's. He used the imagery of anatomy, glowing from within, to represent the spiritual aspect of human life and its connection to nature and the cosmic order of the universe. His networks of nerves and blood vessels evoke invisible structures at the far reaches of scale, from atoms to constellations.

SopheapPich_blogpost

Sopheap Pich is a contemporary Cambodian-born artist who created Buddha 2 (above left) out of rattan and wire in 2009. The openness of its woven reeds allows light to shine through, suggesting the inner body. Pich was a pre-med student before turning to art, and many of his woven sculptures, like Cycle 3 (center) and Caged Heart (right) suggest anatomical forms. But for him, the spirituality of the body is connected to culture and history. His Buddha radiates a peace and calm that contrast with the tips of its rattan strands, dyed red to evoke the blood spilled during the Cambodian genocide.

Ferguson_blogpost

Finally, my own work: Cerebrum, coronal view, with floating colors (left and also above, the header image for the Blog). Curving vertebrae with spinal nerves (center), and Lung, opened (right). I draw from skeletons and cadaver dissections and from radiology images of my own body, made for my use as an artist: a 3D spiral CT scan of my body and a 7-Tesla MRI of my brain. The open access to anatomical source materials that I've gained through my role at the medical school allows me to evoke the subtle textures of physical reality as I draw my own body from the inside out, attuned to sensory and kinesthetic experience.
You can see more of my work at www.lauraferguson.net.

student art_blogpost

The idea for Art & Anatomy, my seminar in the Master Scholars Program in Humanistic Medicine, came out of my own work as an artist. I knew that drawing would a great way to learn anatomy, and a humanistic mode of engaging with the dissection experience and its intimate involvement with the visceral reality of the body. Art & Anatomy is about learning to draw but even more about learning to see: to visualize the inner body and connect it to the the more familiar outside view. The artists are students, faculty, and staff from the medical school and NYU Langone Medical Center, who bring a special perspective to their work: a knowledge and understanding gained through their hands-on engagement with the body and its ills.
Shown above, Pelvis by Susanna Nguy (left) and Under the Skin II by Karen Ong (right). A gallery of student art is on view at http://school.med.nyu.edu/humanisticmed/artandanatomy

As your art editor, I'll continue to present you with images like these, including the work of artists with disabilities and unusual anatomies whose work comes from their own inner body experience and others whose work captures the uniqueness of our inner bodies and helps us connect with them more closely. I hope they will make you think of anatomy and the body in new ways, and show you the power of art to communicate and connect us. I'd love to hear from readers, especially if you have artists to recommend - you can contact me at laura@lauraferguson.net.

Finding a Voice

November 13, 2014 at 5:06 pm

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.

IMG_0477

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.

IMG_0437

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 26, 2014 at 11:30 am

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 16, 2014 at 10:29 am

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.

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

June 23, 2014 at 12:11 pm

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.