The Social Construction of Cancer - Part 3

November 27, 2012 at 11:22 am

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 14, 2012 at 3:54 pm

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 2, 2012 at 12:03 pm

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.


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 15, 2012 at 2:46 pm

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 26, 2012 at 3:16 pm

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.

"Give Me A Shot Of Anything: House Calls to the Homeless"

March 9, 2012 at 4:58 pm

Students at the NYU School of Medicine rotate through Bellevue Hospital during their medicine clerkship. Many of the patients they meet come from shelters or the street. Concern about how their patients live outside of the hospital is a topic that is often raised in the weekly humanism seminar I facilitate, so I was particularly interested in screening the recent documentary, Give Me a Shot of Anything: House Calls to the Homeless, to see whether it would be of interest to my students.

The documentary follows a dedicated physician, Dr. Jim O'Connell, as he cares for people living on the streets of Boston. The project began as a short film about the Boston Healthcare for the Homeless Program that runs the house call program, a hospital clinic, and the McGinnis House, a respite center for individuals who need transition care during an illness and have no home to stay during their recuperation. During production of that film, the director, NY based Jeff Schwartz, was so drawn into the lives of the people he met following Dr. O'Connell, that he decided to expand the project into an hour long documentary.

I interviewed Jeff in his New York studio a few days after he screened the film at Harvard School of Medicine. Following are excerpts of our conversation.

As he spent more time out on the street, the people he met began to open up to him on camera.

As we continued our conversation, I became increasingly uncomfortable with the use of the word "homeless" to describe the people who appear in the film. It seemed to me that it would be just as simple to describe people by name or where they were from, or how they had been trained. The word "homeless" had become a defining rather than a descriptive word, not just in this documentary but in the culture.

During the production Jeff became more attuned to the lives of his characters, and the experience changed his life.

To view the trailer please visit:

-Lucy Bruell, Editor-in-Chief

Painting the Brain

January 26, 2012 at 5:44 pm

Painting the Brain

Rachel Hammer is a third-year medical student and MFA candidate at the Mayo Clinic, and a guest blogger on the Literature, Arts, and Medicine blog.

Medical students are in the process of a professional transformation, and it can be cathartic to express those transformations artistically. One's conceptions of medicine, self, and one's professional identity may cycle through a myriad of forms The Mayo Clinic College of Medicine student interest groups in the humanities and in neurology partnered with the local art museum to host an evening entitled "Paint the Brain" in February 2011. This event consisted of an open invitation to medical students to paint their creative interpretations of the nervous system and the way it creates our human experience. The painting session was preceded by a brief presentation on art theory given by the art center's resident educator, Jason Pearson. Medical student, Lauren Jansons, then spoke on artists whose work has been affected by neurological conditions. Nearly forty paintings were generated.

The majority of the pieces were acrylic on canvas, some were mixed media using fabric, photography, duct tape, or water color. Examples of the artwork include: Andy Warhol-like portrayals of the midbrain, traditional Hmong art as neural gyri, trees of neurons, butterflies emerging from a woman's gut, abstract brains, the landscape of bare calvarium, and one's self portrait in the context of an aura. The paintings were shown on campus for National Brain Awareness Week and at the American Society of Bioethics and Humanities in October 2011. We repeated the painting session in January 2012 with a new topic: global health. Similarly, students were instructed to portray their own representation on the topic. Examples of the artwork from this session included: cervical dysplasia cells as an African mountain range, the earth upheld by many different hands, a closed water bottle hovering in a desert landscape, a woman's portrait overlaid with an anatomical heart, a hospital among gravestones, and a woman looking from a mountain top onto a sea of fog.

Feedback from both sessions was positive. From the first, the neurology student leader reflected, "My painting was inspired by the awe and wonder that filled me as I examined the anatomy of the skull for the first time. The bony cavity that cradles our brains is literally the seat of our conscious human experience and I find the architecture itself very dynamic. The vibrant colors and clear brush-strokes in this painting pay tribute to the constant pulse and flow of vitality through our minds, allowing us to appreciate each new thing."

Another student, a first year, Christine Tran, had this to say: "The painting session allowed me to carve time out of my busy schedule to mindfully focus on something other than the pathophysiology of disease processes or how one cell communicated with another. I didn’t realize it when I signed up to paint but this was a much-needed escape to refresh my mind. I needed to remind myself that… it was possible - and even necessary — to slow down and spend two hours finding just the right shade of beige to paint the contours of a woman’s face, and then to spend another hour giving her hair, highlights, and delicate tendrils. In fact, I enjoyed the exercise so much that when I didn’t complete my painting during the first three allotted hours, I walked back to the museum later in the week in snowy, ten degree weather to spend more time with my painting."

Physicians were invited to both sessions, but very few attended. From the second session, Dr. James Newman commented, "A blank canvas, an unlimited supply of acrylic paint, brushes, and a convivial crew of fellow artists-to-be. The topic was World Health… For me, having painted for many years, but not having touched a brush for too long to contemplate, this was a reawakening. I can't wait for next time."

Shakespeare once penned, "My nature is subdued to what it works in, like the dyer’s hand." So our minds are colored by the mediums we work in. It is refreshing, for a change, to allow color to do what thoughts do.

A Captain of His Ship

January 13, 2012 at 1:15 pm

This week’s guest post is written by Wil Berry, MD, a resident in psychiatry at NYU Langone Medical Center.

My patient, sporting a surprisingly fresh-looking plaid shirt, is sitting at a table in a courtroom on the 19th floor of Bellevue hospital. His hair, in the midst of a transition from sandy brown to silver, falls over his ears but is combed cleanly back to reveal friendly blue eyes. His beard, no longer grimy and tangled, is the color of concrete and full enough to obscure most of his tanned neck. He has been waiting for this moment for most of two weeks, as he has been telling me daily during our fruitless visits, and his posture is stiff with anticipation. I watch him shift his weight form one laces-free sneaker to another, his weathered face showing a softly confident smile, and realize that he looks both profoundly crazy and absolutely not dangerous. And I think, We are definitely going to lose.

The judge comes in, looking at no one, and Mental Health Court is in session. The tone of the regular participants — judge, attorneys, clerk — is flat and uninterested, a contrast to my patient’s jittery energy that makes him seem like a five-year-old at his father’s boring office party. When the clerk tries to swear my patient to tell the truth, he interrupts her to tell her that he can’t swear on a Catholic Bible because he knows the church’s secrets and they are after him. She assures him that he need not swear on any Bible, and he agrees to tell the truth adding "…so help me Christian God, Jewish God, and all gods of the earth."

The attending psychiatrist, my supervisor on the case, speaks first. He says that my patient is psychotic and unable to care for himself, that he has no place to live and has refused to take medication. He says that he is worried that if my patient is released from the hospital in his current state, something bad will happen to him. When he is asked if my patient has been hospitalized before, he replies that our hospital records show thirty-six hospitalizations. In response my patient stands, puts both hands on the table, and says, "Doctor, sir, that is a lie, I have been hospitalized over seventy times!" The judge asks my patient politely to sit down and wait for his turn to speak, and I can see his court-appointed attorney tugging the sleeve at his elbow. He sits, re-composed, saying gently "I’m sorry your honor."

My patient speaks with the unwavering sincerity of a fanatic, his cult composed of his own delusions, his faith reinforced by the doubting psychiatrists who try to diagnose and medicate him. When I first met him, the morning after he had been brought to the emergency room for trying to direct traffic in the center of a busy intersection, I offered him my hand. "Thanks Doc but you don’t want to shake my hand," he said, his voice relaxed and clear. "I just masturbated about twenty minutes ago. My body’s rejecting that chicken they gave us last night." As he stands now, answering questions in that same voice, eye contact warmly fixed on the judge, his demeanor and plaid shirt give him an air of both professionalism and small-town charm.

"Do you intend to hurt yourself?"

"No sir, your honor, absolutely not."

"Do you intend to hurt anyone else?"

"No sir, your honor, absolutely not."

Both parties have fallen into a rhythm, speaking their parts from memory. I wonder if perhaps my patient has spent more time in court than the boyish, court-appointed attorney at his side.

"And what will you do if you are released from this hospital?" Only now does the judge look at him, sliding his glasses down his nose and peering down from the bench.

My patient extends a finger towards the back of the courtroom, the nail long but clean; he is pointing east, to FDR Drive and the water beyond, to the grand and unfulfilled freedom of his future, and the pitch of his voice rises at the thought of it. "I am going to get a boat, your honor. I will be the captain. And I am going to clean up that dirty river."

Afterwards, in a hallway behind the elevator bank, my supervisor asks me why I think we lost. I tell him that I think our patient may have invoked a powerful American archetype, that of the harmless madman, a free-traveling, gray-bearded, hobo-esque schizophrenic who lives by his own code and prizes liberation above all else. I speculate that this symbol is essential to the narrative of our country, of our cities, and of the persistent presence of the seriously mentally ill living among us on our streets. I offer that perhaps it is a symbol which resonated with the court. He tells me that we just got stuck with a bad judge.

While my patient is packing up his room I go and see him to tell him goodbye and wish him well. I offer to see him next week for a follow-up appointment, which I assure him will not take place on the locked ward. He puts the appointment card in the pocket of his wool pants and tells me that he would like to come but doubts he will be available. He smiles at me and tells me that he has enjoyed our conversations. Later that day I sit at my desk, typing up notes and putting in lab orders for the next morning. The window to my right is bolted shut and reinforced with a wire safety guard but if I sit up straight I can see the city stretching southward, lights becoming visible as the sun begins to set. The river is to the east, bridges brimming with evening traffic, the water dark as a shadow between the boroughs, and I watch as a few boats make their way slowly southwards, moving out to sea.


December 21, 2011 at 1:48 pm

Arthur Robinson Williams is a PGY2 Resident in the Department of Psychiatry at New York University. He earned his M.D. and a Master in Bioethics at the University of Pennsylvania School of Medicine and Center for Bioethics. Williams studied photography at Princeton University with Emmet Gowin, Mary Berridge, and Lois Conner. His work, sponsored by an Open Society Foundations Documentary Photography Project grant, can be found at

The University of Toronto Press has recently published an anthology celebrating the 5-year history of its medical humanities journal Ars Medica. I have included excerpts from the article I first published as a medical student in the Fall 2008 issue of Ars Medica that has been reprinted in the anthology. The article grew out of a documentary photography project, MyRightSelf, that I developed with transgender individuals and couples in the Philadelphia area over the course of 2008 which was subsequently funded by an Open Society Institute Documentary Photography Project grant. Now working as a second-year psychiatry resident, the publication of the anthology has given me an opportunity to reflect on my travels- academic, clinical, spiritual, photographic, and otherwise- in the intervening three years.

Dane and Erin. "There are always things I think people would change about their bodies. I know no man whose chest is big enough, hairline is stable enough, abs are eight-pack enough. I don't think I am above all these influences. I wish I were taller and I wish my chest were without scars. Although they are fading slowly, my scars are pretty prominent."

Most striking is the loss I feel in acknowledging that this project was the last significant work of photographic portraiture I have completed. While I have occasionally engaged in some landscape work while vacationing, my long hours in the hospital during residency have largely eclipsed other meaningful forms of engagement and creativity in my day-to-day life. I have also found that successfully living in New York City demands its own toll- the scale, expense, and cacophony of the City adding to the fatigue engendered by 14-hour shifts.

Perhaps those are excuses however, rather than true explanations for the distance that has grown between my photographic lens and potential subjects. I remember writing in my personal statement when applying to residency programs:

The psychiatrist and the photographer have much in common. Whether relating to another person as a patient or a subject, both contemplate notions of identity and perception, of the Self. Both, at their best, similarly investigate their own biases in understanding those of others. Perhaps this is why Psychiatry felt so familiar to me- it was a role that I had already cherished. Part of what I was seeking in medicine was the opportunity to sit with someone, to be available to them, to learn more about the human experience.

Jake: "I gained confidence in my ability to pass, not only physically, but socially as well. From there I started going to gay bars-not to hook up, but just to be there, to be around gay men, again, to be in gay space that I felt safe navigating. I liked letting gay men flirt with me. It made me feel validated in my gender.

Clinical work in the mental health field is emotionally draining. I wonder if the reserve I needed to make photographic images has been otherwise spent on treating patients. The average doctor's day is filled with images, some radiologic, some metaphorical, others directly observed. Psychiatrists especially cultivate these images, drawing anecdotes, memories, and projections from their patients. The investment in this process consumes creative spirit as well as pathos. From Ars Medica:

For the participants with whom I have worked, the act of making a photograph has become-should be-as cathartic as the knowledge that the images will eventually reach a broader audience and as profound as the impact of the images upon viewers. For patients, likewise, the journey toward diagnosis and treatment may have as marked an impact on their latter years as their medical condition and/or disease state.

As a provider I have struggled not only to successfully complete a work up and treatment plan, but to find ways to enrich the process itself. Medicine-as-process, as a creative form imbued with empathy, becomes its own artistic medium in the act of naming and thwarting disease. Maintaining energy to do this well requires a source of renewal. I look forward to the day when once again this source may be found behind the lens.

A. Robin Williams, MD MBE
December 8th, 2011

Body and Soul: Selections from Ars Medica: A Journal of Medicine, the Arts and Humanities, was recently published by The University of Toronto Press. It is available at Caversham Books: (

Humanity Out of Context: Tinkers as a Touchstone for Dissection

November 3, 2011 at 3:19 pm

Editor's Note: I met Rachel Hammer, a third year medical student and MFA candidate at the Mayo Clinic, last month at the American Society of Bioethics and Humanism conference in Minneapolis where she presented a poster about a student poetry group. When I mentioned that I worked at Bellevue, she told me about a recent meeting at the medical school where the novel, Tinkers, was discussed in a narrative medicine group. Tinkers, as many of you know, was published by the Bellevue Literary Press and received a Pulitzer Prize for fiction. I asked Rachel if she would write about the group and its discussion of Tinkers.

Commentary by Rachel Hammer, MS3 and MFA Candidate, Mayo Medical School

The Mayo Clinic College of Medicine's Narrative Medicine group started in response to an ornament in Evelyn Waugh's Brideshead Revisited. A skull sits in a bowl of roses in the dorm room of Waugh's protagonist, Charles Ryder, in a section entitled, "Et En Arcadia Ego." Arcadia, legend has it, is the field described by Pliny the Elder where a shepherd wet his finger with spit and traced his friend's shadow against a tomb-the first painting-suggesting whilst setting the precedent that art is inspired when humans face their mortality. Art, thus, is humankind's response to death.

After hours in the medical school anatomy lab in the first year, we had stared at skulls and the dead long enough to stir substantial need for creative expression. A group of us began to meet to read poetry and excerpts from novels. I had read Rita Charon's Narrative Medicine, and visited the Masters Program at Columbia, where I learned some basic exercises in "attention, representation, and affiliation" and so I offered to facilitate the sessions. We are graciously funded by the Walt Wilson Art in Medicine grant. Our group meets for lunch once a month and is open to all medical students. Students sign up to attend, and we cap the group at twenty members. I choose the excerpts, usually something I come across in my MFA coursework.

For the October meeting I chose to read from Tinkers by Paul Harding, a work that I thought would resonate with first year students going through the emotional and physically arduous anatomy block. The excerpt (pages 178-184), was the touchstone for a discussion on experiences of cognitive dissonance when bearing witness to humanity out of context, such as the discomfort one may experience in dissecting a cadaver.

Tinkers is broken into segments with alternating narrators, Howard, the father, and George, his son, each tell the stories of their lives, with modest overlap. Real time in the book works backward, counting down the last days of George's life; time within memories works forward. Father and son as co-protagonists are like two gears, intimately related and yet spinning with force and purpose all their own.

In the excerpt, George, near death, loses consciousness in the living room where he lay in his bed surrounded by family. As always in our Narrative Medicine group practice, we read the passage to ourselves, closely, deliberately. Then we read the passage again, together, aloud. We then discuss what we recognize, what surprises us, and what it means to us, today, as we chance to encounter it.

We were struck by the language of natural elements Harding used to describe the dying bodies: Salt, wood, minerals, legs like planks, feet like lead weights, salt-cured, metal strengthened, dried veins, strong as iron chains, exhausted engine, bushings. Someone remarked that in other settings, when humans are described reductively in terms of their elemental components, their inner workings likened to the machinery of a clock, we are repulsed. How dare we consider humans as mere material! But in the space of death, written with the reverence of a poet, George returning to mere material is a beautiful, honorable fate. Recognizing that George spent his life as a clockmaker-that there was nothing for which he had more passion than clocks-his, then, is a righteous transfiguration indeed; that in death, he would morph to resemble the very thing he most loved in life, the wood, the chains, the lead weights, the bushings of a clock.

One student linked the end of the passage (p.184) to themes of TS Eliot (The Four Quartets was a previous reading in this group). She recognized the confusion of time in the space of death and grief-"imagining was as it is still approaching"-as a collision of past and future. Sharing our fears of death for ourselves, worry of bodily pain, we saw in ourselves the family Harding describes hovering around George:

(…"that they mourn because of the inevitability of the was and apply their own wases to the it [dead body], which is so nearly was that it will not or simply cannot any longer accept their human grief) as its broken springs wound down or its lead weights lowered for the last, irreparable time."

We discussed the extent to which our efforts in palliation and comfort are more for the provider than the patient. How some things are irreparable, and how seldom we can admit this to ourselves.

Since this passage was intended for the reflection of the first year students, as they loom over their assigned dead bodies like belated Fates, I asked them to reflect on the language in this passage while contemplating what it means to be dead, and what it means to encounter the dead. As you pick away at the crust of another human, now lifeless, out of context, consider the story that lies beneath. Our bodies, universes unto themselves, are, in fact, neither simple nor always logical, but ever so elegant.