Medical Humanities: Sowing the Seeds in the Himalayan Country of Nepal

April 14, 2008 at 4:43 pm

Composite Nepal Photgraphs by P. Ravi Shankar
Commentary by P. Ravi Shankar, M.D., Department of Medical Education, KIST Medical College, Imadol, Lalitpur, Nepal

Nepal, a country in the lap of the Himalayas is still predominantly agricultural. The majority of the festivals and cultural events have a strong correlation with the planting and harvesting of rice, the principal crop. With the hard rocky soil and the lack of suitable flat land it is difficult to cultivate crops in Nepal. Agriculture like in most of South Asia is a gamble dependent on the vagaries of that great seasonal phenomenon, the monsoon. Adequate rainfall at the right time is the major determiner of whether the sown crops will yield a good harvest and can mean the difference between eating well and going hungry. I was taking a similar kind of risk with an initial voluntary Medical Humanities module in the Himalayan country. Whether I would be successful at the end of the day depended on a variety of factors, the chief one being the enthusiasm and interest of the participants.

The PSG-FAIMER Institute

It was early January 2007 when I came to know about the PSG-FAIMER regional institute in Coimbatore, India through one of my good friends. PSG is a charitable group who run a number of educational institutions in Coimbatore, India and FAIMER is the US-based Foundation for the Advancement of International Medical Education and Research. The institute was inviting applications for a part-time fellowship in Medical Education and was inviting an outline of curriculum innovation projects from potential fellows. I have always been interested in medicine from a ‘different’ perspective. I have a keen interest in the history of medicine and am also interested in literature and creative writing. I am a keen trekker and photographer and have spent many weekends and vacations in the delightful trekking areas of Nepal. Most of my contemporary fellows (mainly from India) had chosen projects well within the confines of the curriculum. However, I wanted to do something that pulled together my interest in history, literature, and art within the framework of medicine, something along the lines of what is called Medical Humanities in the west." I discussed my proposed curricular innovation with Dr. SK Dham, dean of the Manipal College of Medical Sciences in Pokhara, Nepal, and he was very supportive. I decided to submit my project and hope for the best.

The first on-site session

It was a delightful experience to receive the e-mail from the institute confirming my selection. The first on-site session was to be held in mid-April at Coimbatore and I set about working on the project. At Coimbatore we were taught about project planning, force-field analysis, concept maps and looking at the project in a structured fashion under various headings. The overall attitude towards my slightly novel project was positive though there were occasional suggestions to choose a more conventional subject. The food at Coimbatore was a delight and I could not have enough of idlis, dosas, upma and other South Indian delicacies.

Initial days of the project

On coming back to Pokhara I started work on my project in earnest. The first task was to obtain feedback from the stakeholders and design a curriculum. One of our faculty members at PSGFAIMER was Dr. Janet Grant of the Open University, United Kingdom and she was kind enough to send me material on curriculum design. For a long time I had been intrigued by a feature in the journal Academic Medicine titled ‘Medicine and the Arts’ (MATA). I wanted to contribute and wrote to Ms. Anne Farmakidis who was in charge of MATA at that time about how I should go about writing a MATA article. She gave me a few hints and was kind enough to send me a copy of the book titled Ten Years of Medicine and the Arts. The book’s a compilation of MATA articles published over the years from 1991 to 2001. The book was a delight to read and I was hooked! This book was also a key factor in strengthening my interest in the medical humanities.

Preparing for the module

The module I was planning was voluntary so maintaining participant interest was the key! I had noted that in many courses of study in South Asia the objectives are not clear. I resolved to put down the objectives of each session on paper in black and white. Ironically I ended up with clearer objectives for a ‘soft’ course like Medical Humanities than for courses like Anatomy or Pharmacology! I also set about constructing a student guide, a facilitators’ guide, a guide to further reading, and session descriptions. A major question in my mind was how many sessions should be conducted. I wanted the module to serve as an introduction to the fascinating topic of medical humanities. As part of the course I was in touch with my friends and faculty at the PSGFAIMER Institute through a listserv and we started discussing how to go about our respective projects. We also cover various topics related to health sciences education every month. As medical humanities is not well developed in South Asia I got in touch with various medical humanities educators from other regions through e-mail. All were gracious enough to respond and offer their suggestions. All wanted to help kick start medical humanities in a developing Asian country. I owe a special debt of gratitude to Dr. Johanna Shapiro of the University of California at Irvine, Dr. T. Jock Murray of the Dalhousie University Faculty of Medicine, Canada and Dr. Tom Tomlinson of the Michigan State University in US. My friend, Dr. Rakesh Biswas was also very helpful.

Learning modalities

I finally decided to conduct fifteen sessions divided into three units titled Medicine and the Arts, Ethics and Medicine, and Contemporary Issues in Medicine. There were also home assignments. A major goal of the module was to make learning fun and avoid the heavy, boring didactic teaching which is in vogue in most of South Asia. Learning sessions were to be conducted in small groups and were to be activity based and interactive. Literature and art excerpts, role plays, case scenarios were among the different modalities used to explore various aspects of the humanities. Medical humanities was not widely known and it was up to me to popularize the term and what it meant. MCOMS has two campuses with the basic science campus being located at the scenic and wooded Deep Heights in Pokhara. The students run a wall magazine called Vibes and I often contribute to this delightful magazine. (A wall magazine is like a notice board and various articles and features are put up on the board. The contents are changed regularly and a particular collection of articles and features constitutes an issue.) I wrote an article about medical humanities for Vibes.

Sources of literature & art

For the module I mainly used literature and art excerpts from a western context. I was able to use a couple of excerpts from South Asian authors in the module. Photos of the violent conflict in Nepal were used and the majority of the participants could easily relate to this. A major difference between America and Nepal is that in Nepal, like in most of South Asia the student-teacher relationship is authoritarian and hierarchical. I had to make sustained efforts to get the students to open up. The case scenarios and role-plays were designed by me to reflect various aspects of the practice of medicine in Nepal and south Asia and were well received by the participants.

Canvassing for volunteers

I started canvassing support among the students of the clinical semesters. In Nepal the undergraduate medical course is of four and half year duration and is divided into nine semesters. The first four semesters are devoted to the basic science subjects and the last five to the clinical ones. Initially I concentrated on the fifth semester as the students had just entered the clinical phase and were the most ‘free’ batch of learners. However, the fifth semester also runs a program to help the poor patients of the hospital — the socially aware and active students were active in the poor patients’ fund and had no time for medical humanities. I then turned my attention towards the sixth semester. I started canvassing among faculty members to join. My colleague, Subish is keenly interested in the more rational use of medicines and other issues as well; he enthusiastically participated in the module. He was instrumental in providing the excellent facilities of the Drug Information Center Conference room for the sessions. The room helped to create a relaxed, protected and comfortable atmosphere.

Initial days of the module

The initial sessions were a touch and go affair. People kept coming to the sessions and dropping out. Some of them were irregular in attendance, attending scattered sessions. Gradually word spread about the unique module. Participants started coming and staying! A sixth semester student came to test the waters; she found it was to her liking and more of her friends joined. One of my colleagues, a physiologist, trekker, artist, photographer and many other things besides was an enthusiastic participant. My clinician friends were generous in sharing their rich clinical experience as co-facilitators. Another colleague had done his doctorate in Denmark, where, as in most of Europe, it is expected that medical and other health science students know some philosophy. With his help I started a ten minute discussion on philosophy during the module. One of my students then in the final year of medical school asked me to contribute an article about medical humanities for the college magazine, Reflections which they bring out.

Sessions for the Basic Sciences

The students in the Basic Science campus requested me to conduct a module for them. It was difficult to find a time period convenient to both the parties and finally we settled on the lunch break. It was indeed gratifying to note the enthusiasm of the participants. This module was conducted along the same lines but each session was divided into ‘bytes’ spread over three working days.

Novelties of the module

The module introduced a few new concepts and also further developed certain others which I had been using in my small group sessions for students. Constructive formative assessment, reflective writing assignments, assessment of the facilitator and faculty and students learning together were a few of them.

Module at KIST Medical College

At present I am conducting a module for faculty members at the KIST Medical College and these members could be used as co-facilitators for future sessions. I really enjoyed being a part of Humanities 101 and I am sure my student and faculty participants did too. I sincerely hope the seed of medical humanities will take root in the fertile soil of Nepal (among the highest countries on Earth) and bloom among young, energetic and impressionable minds!

Connections

April 1, 2008 at 9:35 am

Fluorescent cranial nerves
Commentary by Madge McKeithen, M.F.A., writer, and teacher of writing at The New School, New York City

A poem…can uncover desires and appetites buried under the accumulating emergencies of our lives, the fabricated wants and needs we have had urged on us, have accepted as our own. It’s not a philosophical or psychological blueprint; it’s an instrument for embodied experience….After that rearousal of desire, the task of acting…is ours.
Adrienne Rich. "Voices from the Air." What is Found There

Picking up a line

The first symptoms of my son's illness appeared in the second half of 1997. Diagnosis eluded the numerous doctors we consulted. By 2001, symptoms had appeared and worsened to the degree that a special living situation for him and a modification in my professional life were necessary. I left fulltime teaching for writing and a degree that would allow me to teach writing; I began reading poems avidly and writing the story of my son's illness in response to the poems. Blue Peninsula, published in 2006, came from that situation and experience.

Over the last two years, as I have read from this book publicly and in medical and academic settings, I have found myself not infrequently in the middle of conversations that are not fully happening — what could be vital and creative exchanges falling short between health care providers, medical humanities faculty, and the general population (past or future patients). As a writer, a teacher of writing, and a mother of two sons, one of whom is likely to keep us engaged with the medical community regularly and long-term, I ask, "Why the divide, the compartmentalization, the parallel and transverse monologues when literature and the arts offer expanding connections?"

Following it along

Literature is being engaged on multiple sides of the physician-patient dialogue. Medical humanities and narrative medicine programs are offering medical students, residents and physicians the power of literature and art alongside their clinical practice. Patients and advocacy groups are bringing literature into the patient experience as well. And on each side, regular examination of the value of the undertaking, a sense of marginalization, and a desire for a more expanded, richer connection with others involved in similar programs are close to the surface. Good news. Websites, databases and blogs such as this one are connecting the dots, and fledgling programs are benefiting from learning about and possibly collaborating with more established programs.

Facing illness from anywhere in the room can be a lonely business. Why not look wherever possible for connections? Why settle for connections being spotty and erratic, the exception and not the norm?

Time — is the common, unsurprising response. The pace around health and illness can be fast, sometimes urgent. Time as an important factor — important to medical education decisions, to delivery of care, to quality of care and cost considerations, and to the limited resources and energies of all involved — is hard to deny.

Crossing it with others

When I first discussed with a few friends the poems I had collected and how I thought I might use them to tell my son's story, a poet said, "Invite the doctors to leave clinical time to enter poetic time, if only for a little while." As I have suggested "poetic time" to audiences of neurologists and senior citizens, college students and professionals before reading from John Donne or Emily Dickinson or W. B. Yeats, the nods of comprehension have been almost instantaneous.

I invited them to step to the side of the moment's rush, to let a poem hold us temporarily in place before returning to the other content at hand with something we had not, perhaps, been able to identify beforehand as being needed. At Mayo Clinic, the poetic time provided a place from which to consider how to communicate with a patient whose 18-month-old daughter's condition could not be diagnosed until symptoms worsened, a place from which to admit the emotional strains of being the specialist at the end of a long line of unknowns. For senior citizens who spend more time than they would wish in doctors' offices, the poetic time allowed consideration of insecurities, frustrations, and then, the surprise of common ground.

Time, reconfigured by poetry, allows connection.

Cross-disciplinary endeavors in health and humanities are yielding good fruit - hybridized perhaps, new, challenging classification and valuation. Communications and connections are growing and regenerating among the innovators in the field. Is more possible?

Stretching further

Embodied experience, Adrienne Rich's words come back. Actions, small and large, fully experienced and communicated. Internet sites providing descriptive and evaluative information about programs, forums for sharing initiatives and experiments, joint presentations at conferences and workshops, writing, reading, publication.

I imagine a doctor and a patient facing a tough situation, a diagnosis difficult to deliver or to make. I imagine neither of them wanting to be in that conversation. What poem might each hold (figuratively or literally)? What one between them? Many come to mind — part of the beautiful multiplicity of poetry. The patient's poem might invite her to consider herself both fully flesh and more than her illness; it might achieve its lift or transcendence with a surprise twist of humor. The one in the physician's pocket might also invite an approach to grasping his humanity, a setting of resolve or the loosening of familiarity. And between them they might, as William Stafford writes, stumble on words, "a program of passwords. / It is to bring strangers together."(Ref. 1) An important difficult conversation that might not have happened does.

The intersections of literature and medicine, health and humanities, patient and physician bring up real possibilities for new and expanded connections that themselves may generate new possibilities, discoveries, and ways of thinking. William Carlos Williams queried "What kind of a mind…is most likely to make useful discoveries" and answered, "the mind which will be human in its perceptions and skilled in transverse, not perpendicular ways." (Ref. 2) Not only whether but how we connect across these divides will change outcomes. The experience and desire are engaged, the task of acting…is ours.

References
1. William Stafford. "Passwords." In: Passwords (New York: HarperCollins) 1991
2. William Carlos Williams. The Embodiment of Knowledge. (New York: New Directions) 1974, p. 64

 

 

The Story of C.: Teaching Poetry to Children with Disabilities

March 13, 2008 at 10:46 am

Nicole Hefner and one of her studentsCommentary by Nicole Callihan, Teaching Artist for Teachers & Writers Collaborative and Language Lecturer at New York University

Spring seems to be rearing her pretty little head again, and I find myself back in the Staten Island classroom working with students who have moderate to severe cognitive and mental disabilities. It is a welcome respite from my New York University classroom where we discuss ideas and complicated syntax, organic forms and rich tension. In the Staten Island classroom we are terribly content with nothing more than the small glittery cardboard box that we call the "Magic Poetry Box."

Each week the Magic Poetry Box is presented with great fanfare. After the oohs and aahs (given without a trace of irony), a student volunteers to reach in and unearth the day's lesson. On Valentine's, the box contained hearts, and we wrote love poems; on a particularly gray day, a tiny squirt bottle of "rain" was tucked inside, and we wrote March Rain Songs. Yesterday, though, the box contained nothing. I thought C., a nine year-old boy with autism, might cry. "Nothing?" he asked. He grew panicked, rocking back and forth in his chair. "Nothing?"

"But wait," I said. "I think I hear something." I pulled the box close to my ear. All six students (all on the lower functioning end of the autism spectrum) looked at me. They waited. Before we knew it horses galloped, dogs barked, wind blew, and we were standing on the beach getting ready to fly to the sun which would, they told me, keep our wings warm.

This is my tenth year of working with students with autism. I had no formal training, and my knowledge, like so many other Americans a decade ago, was limited to Dustin Hoffman's portrayal of Raymond Babbitt in the film Rainman. In the years since, autism has come to be far more recognized and diagnosed. Everyone seems to know someone whose son (boys diagnoses far outnumber girls) has some form of autism. But even with the prevalence, we still know so little about the condition.

I was at a loss when I first entered the classroom with these students. I had been accustomed to working with second and third graders for whom the "imagination" was the Ferris wheel of the mind. They loved it. "Be a shell," I'd say, and they'd whip up notebook pages filled with stories of basking in the sun, of Puerto Rico and mangos, of being found by a lonely little girl who ever so gently brushed the sand off the edges. "Be a bear! Be love! Be anything! Just pretend," I told them, and they did.

But my tricks got me nowhere in the new classroom. The students didn't even stare blankly at me. They stared away, one biting his hand, one banging the table, the others simply not there. As I was leaving, the teacher pulled me aside. "They don't really get the imagination thing," she said. It was winter, and I was in Harlem. I had a long walk to the subway station, and even now I remember the bleak ice patches on that walk and thinking "The imagination thing? What do you mean they don't get the imagination thing?"

For years, I took this advice to heart. I read up on how children with autism thrive on repetition and systematic learning. I would hold up a blue circle, make them touch the circle and say blue. "Blue," they said over and over, one by one around the table: "Blue, blue, blue." But something was still missing. Yes, the students were "doing the poetry lesson," but there still lurked a terrible lack of connectionaand connection, if you've ever known someone with autism, is exactly what you crave when you're near them.

Trapped by the monotony of that blue circle, my lessons grew increasingly animated. I thought that if I could flap my wings hard enough or raise my voice loud enough I could actually getaand possibly even keepathe much coveted eye contact. I was careful, though, very careful about the way in which I approached issues of the imagination. We weren't birds; we moved our arms as if we were flying like birds. I tapped into two things, however, with this last bit of arm-flapping.

What I first came to realizeaand have employed ever sinceais the necessity of a movement component in working with these students. They respond particularly well to yoga, but any sort of directed movement speaks to them. It seems that once the body really gets to move, the mind follows. I also realized that with enough repetition of imagining the students found that they could use their own imagination. It was as if we had exercised that muscle as well.

Years ago, I replaced my blue circles with the Magic Poetry Box; the "color drill" was no longer satisfying for anyone involved. Yesterday, though, was the first time I took the risk of letting the box contain "nothing." We passed the box from student to student, each one holding it to his ear to tell us what he heard. When I got to C., I was a bit nervous as he's known for his very physical fits of frustration. "Can you hear anything?" I asked him. I looked over to one of the teachers who shook her head ever so slightly and shrugged. "Anything at all?"

C. was silent for some time. I couldn't shake the fear that he'd push the chair back and fly into a rage breaking the delicate atmosphere that the teachers and I worked so hard to maintain. I played the lesson over in my head wondering why I hadn't just brought in shamrocks or a lucky pot of gold. I thought back to the teacher from Harlem who had so long ago warned me about the imagination thing. And then, finally, C. spoke, "dog?" he said, almost asking, but then he said it again, louder. "Dog," he said, "barking. Barking loud and chasing a cat." And we clappedathe other students, the teachers, me, even C. clapped. The rest of the hour slipped past us, and we said our goodbyes as I placed the lid back on the small empty box.

It's interesting because there are days when I've felt silly carrying that box into the school; its campy unveiling has struck me as ridiculous, its paper hearts clumsy. But yesterday, carrying the box down the well-lit hallway, the box was nothing short of what I've been calling it for years: magic, absolute magic. I can only hope that it will continue to work its magic in the years to come, letting imaginationsaespecially those that seem locked so deep withinafind their way to the delicate surface.

Writing And Medicine: Making It Up As You Go Along

February 26, 2008 at 10:21 am

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004
Commentary by Perri Klass, M.D., Professor of Pediatrics and Professor of Journalism at New York University, and Medical Director of the national literacy program, Reach Out and Read

Many many years ago, I think back when I was doing my residency, someone asked me to talk about the connectionsaor the differencesaor maybe the balance between writing and medicine. I was neckdeep in medicine, of course (or maybe it would be a truer metaphor to say that I was often out of my depth), and I was trying to write both fiction and nonfiction, as I could, along the way. I was therefore a de facto expert in what writing and medicine did or did not have in common, but as is so often the case with de facto expertise, it was a long way from anything I had actually thought through, let alone tried to articulate.

But though it may not be quite as effective as the knowledge that one is about to be hanged, the need to prepare a lecture does concentrate the mind, and so I eventually sat down to make some notes to myself about writing and medicine. Since much of my non-fiction writing at the time (and still) was drawn pretty directly from my clinical experiences, I put that to one side, and instead found myself thinking specifically about the ways in which writing fiction brought experiences and intellectual sensations and challenges into my life. And I came up with three ways in which I decided to argue that writing fiction balanced out residency. And now, a couple of decades later, I still find myself reaching for those ideas, whenever it comes time to discuss writing and medicine, two subjects still much on my mind, and much in my life. And I have to admit, I find myself wondering whether I reach for them because they happened to be the three points I invented for myself under pressure, when I had a lecture to give, or whether they were the three points I invented in the first place because they so resonated with the different parts of my lifeaand my brain.

Putting It Into Words

First of all, I said, in medicine, words mattered for the information they conveyed. If you could get the information across, if you could identify the correct term, you were using words appropriately (and "appropriate" is still one of those words that I never use without feeling I am taking refuge in a mildly unpleasant piece of pseudo-medical jargon). You don't have the luxury of using words for the sake of beauty or harmony or impact as part of daily clinical medicine; you wouldn't choose to spend twice as much time (or space) discussing a clinical situation, just because you had thought of an interesting and novel way to use language, or a less-than-straightforward structure in which to tell your story. On the other hand, there is no limit in fiction save the boundaries of your own genius (or lack thereof); the way you use your words is all. Go ahead and tell the story backwards, or inside out, go ahead and let the real story unfold by implication, make it as simple or as complex as you like, make your sentences deliberately brusque or stunningly lyrical; make your story structure as direct or as oblique as you like. The only limitation is your talent, the only measure is your success. Using the language in a bold new way may turn out to be a wonderful ideaaor a disasterabut the choice is yours.

Second, I said, medicine was a culture of availability, of turning yourself outwards and listening for various kinds of calls and cries. Clinical practiceaand most especially residencyawas about being on-call, being on the spot, being findable and reachable and moving fast when someone needed you. I invoked the beeper, of course. I described the "fishbowl" on the pediatric ward where I trained, the many-windowed room where residents sat to write up charts, easily and deliberately visible to every passer-by. Writing fiction, on the other hand, means shutting yourself alone in a room, looking deeply into what is there in your own mind, your own imagination, your own experience. Instead of listening for beepers going off and questions to be answered and cries of distress, you turn your attention to characters and stories that no one else can see or hear, until you have made them real.

And finally (and this was my socko finish), when you write fiction, you get to choose the ending. You get to decide who lives and who dies, who has what we would call (in the language where "inappropriate" means anything from wrong to crazy to rude) a good outcome, and who has a bad outcome. And the single harshest lesson of medical training, after all, is that while of course you do your very best, you don't actually get to determine the outcome and choose the ending.

Telling Stories About Telling Stories

Well, a couple of decades later, I still write fiction. And I still value it for what it adds to my life, for the ways it pushes my brain out of intellectual routines and into unfamiliar pathways. But even as I occasionally go on citing my three distinctions, I've come to believe that they are oversimplifications which shortchange both the complexities of practicing medicine and the challenges of writing fiction.

Take language. It's true enough that language carries a different value in fiction, where there is always the possibility of finding language which transports or shatters, shocks or overwhelms. And after all, if you were a writer of genius, you would find that languageawriters of genius somehow manage to do just that. But language in clinical practice is much more than the efficient coding of patient histories into the formula of case presentation and progress note. Language in clinical medicine is also the currency of communication and explanation, and it encompasses tragedy and confusion, resilience and generosity. I think about the many ways over the years that I have tried to find words to convey unwelcome information, and the many ways that parents have found to evoke their lives and their emotions and their questions. Sometimes there have been questions and comments that stayed with me for their poignancy or their beauty or their unexpectedness, like the teenager who asked me, "What do you do when your body really wants to do something and your brain isn't sure?" I have come to realize that the language of the exam room is the language of people narrating their lives, making up their own stories, or finding ways to articulate and examine the stories in which they find themselvesaand that the language there, as much as in anything a writer sits down to write, cannot be separated from the story.

Or consider availability, collaboration, inward-ness and outward-ness, whatever you want to call it. I think I always knew this was a somewhat false distinction; I would never write fiction if I did not spend time out in the world, mixed up with other people and their lives. It's true that sometimes writing can serve as a retreat, an interval of consideration and examination, even meditationabut I've never been a writer able to write out of the rich and glorious furnishings of my creative imagination. The inside of my head is hung with the scavenged scraps and the mismatched patches of my daily life, and what I do when I "turn inwards" in that rather affected phrase of mine is take the time to look more carefully at what I've carried home.

And finally, there's that issue about choosing the ending. Every writer who has struggled with fiction knows that isn't necessarily true. Characters don't do what you tell them to, or you find yourself disliking someone you had created and expected to find wholly admirable, or you watch in shock as two of your characters inexorably move into a doomed and destructive relationship. I mean, probably if you write certain kinds of formula stories, your characters do as they're told; if it's a romance novel, and the talented, spirited, but cynical and defensive heroine (oh, and beautiful, did I mention beautiful?) takes a job as sous-chef to a demanding, brilliant, but severe and critical chef (oh, and he's amazingly handsome, did I mention amazingly handsome?), and they dislike one another on sight…..well, probably they will behave themselves and fall passionately in love among the saucepans by page 120. And that's fair enough. But characters have a disconcerting way of speaking up for themselves ("The hell with the chef; I think I'm falling for that punked-out waitress with all the piercings!"). I have several times had the experience of coming to like and understand my villains much better than I had ever meant to do, or even worse, watching my heroes and heroines evolve at least a little in the direction of villainy, as it turned out their motives were less pure than I had planned, their standards of behavior a little less lofty.

So yes, when you write fiction you get to choose the ending. But it isn't always the ending you thought you were choosing, or the ending you wanted. In the writing of fiction, as in the practice of clinical medicine, you can learn a lot by listening carefully and watching closely. And I'm not sure there's really a good or useful distinction between the language of daily life and the more writerly language of literature; stories cannot be dissected out from the words used to tell them. And every story, as it is formulated into words, carries the potential to shake you up or shock you or move you in a variety of directions. It's about listening carefully to the characters, and valuing words in many different ways, it's about figuring out the ending, whether or not it's the one that you were hoping for (or that the characters were hoping for), and perhaps it's also about understanding, as a doctor or as a novelist, how your own limitationsalike your own abilitiesaare part of the language and the story and the outcome.

Biocultures: Take 2

February 11, 2008 at 2:27 pm

Designer babies, Rowena Dugdale, Wellcome Library, London
Commentary by Bernice L. Hausman, Ph.D.,Department of English, and coordinator of the undergraduate minor in Medicine and Society, Virginia Tech.

On December 29, I acted as respondent to a panel on biocultures at the Modern Language Association meeting. The panel, "Biocultures: An Emerging Paradigm," was organized and chaired by Lennard Davis, who read from the manifesto (written with David Morris) introducing the recent issue of New Literary History (vol. 38, no. 3, 2007) discussed by Brad Lewis in his August entry to this blog. Jonathan Metzl gave a paper on "Protest Psychosis: Race, Stigma, and Schizophrenia," while Jay Clayton spoke on "Victorian Epigenesis: Inherited Behavior without Genetics." This blog entry is an edited version of my remarks.

Data and truth

Every year I lecture to the Careers in Medicine class at Virginia Tech on the social contexts of medical practice. This fall's lecture was "Against Health," inspired by a conference put on by Jonathan Metzl at the University of Michigan in 2006. Based in a Foucaultian paradigm to explicate the normalizing effects of biopower, the lecture challenged the idea that "health" is an unalterable good based in the truth of scientific evidence. I had focused on the problem in making "health" the goal of life a not a means to a good life, but a substitute for life altogether, such that working for health has become a major preoccupation for many people and is now a measure of goodness, morality, and righteous living. Since "science," through what is now called "evidence-based medicine," provides the ballast for concepts like "health," "health" is unassailable. "Health" cannot be challenged because it is based in the truth of scientific study. But that is only through a very narrow framework for analysis a the same kind of framework that suggests that one's eating habits should be determined by the results of a blood cholesterol test rather than cultural traditions or the local availability of various foodstuffs. I was trying to dislodge this narrow framework by suggesting its stresspoints and problems, by highlighting the historical particularity of lifestyles framed by scientific studies and medical prognostications.

At the end of the lecture, one frustrated premedical student asked me, "what's your data?"

As Lennard Davis points out in the manifesto, "data" is a point of contention between the sciences and the humanities, despite decades of excellent research in science studies. Indeed, we still operate with the understanding that in the humanities we have "critical thinking (i.e., no data) while in the sciences there is strong data, usually conveyed in numerical form. Having no data is tantamount to having no truth. In the cynical view, "critical thinking" might be figured as that activity one engages in the absence of any clear truth, the intellectual game one plays with no data. "Critical thinking" is what the humanities offers the world, but only because the field is perceived to lack true data and the valuable facts that emerge from it.

Why we need biocultures

Any biocultural synthesis thus faces the degraded profile of the humanities in public culture and the hegemony of "science" over "truth." Even in arenas where humanistic knowledge might be especially helpful, it is absent or denied. At the 2006 International AIDS conference in Toronto, the social sciences made it into the program, but the humanities were completely absent. One session I attended addressed "controversies around prevention strategies for sex workers and injecting drug users, showing how politics and ideologies are pitted against "good science"." At this session I was struck by two assertions a 1st, that good science is as an antidote to politics and ideology, and 2nd, that scientists are equipped to identify and overcome ideology. I suggested, in keeping with Len's claims, that in addressing these issues, "scientists should look to . . . humanists and interpretive social scientists who think about the work of ideology and its sociocultural effects."

This is precisely the kind of intervention that Jonathan Metzl is making in his research on the racialized meanings of schizophrenia in the twentieth century. His claim does not merely concern the social determinants of disease categories and understanding, but addresses how the diagnostic process itself is racialized. He argued that schizophrenia actively functions to "enable mainstream America to grapple with" effects of the Civil Rights movement on the meaning of America; this claim demonstrates how biocultural analysis understands diseases as "disease entities," in Len's words. Jonathan's project moves us closer to Len's suggestion that "experiments using 'race' [would] be better a produce more reliable facts a if they employed a biocultural notion of what race in fact means." Feminists have connected mental illness diagnoses to normalized and heavily gendered cultural scripts; it is time to determine how race figures in the construction of mental states and disease entities.

But how do we keep biocultures from being another form of enhancing science's own projects, especially ones that misrecognize the existing and potential contributions of humanistic inquiry?

This is the problematic addressed by Jay Clayton in his paper on the new Neolamarckian epigenetics; he suggests that in policy contexts, "our (that is, humanists') absence from the room skews the resulting image of culture." The time is ripe, he argues (although without cliche), to move into the policy arena through the specific study of literature and an understanding of its historical embeddedness. This deep understanding, as opposed to the vague gesture toward literature as the repository of timeless values, allows literary humanists to engage knowledgeably in the important ethical and policy debates surrounding new technologies, practices, and aspirations in the biosciences. We must enter into what Jay calls the "semi-autonomous realm of policy" a the institutional context that, in his words, "gives critique at least a chance of having real consequences."

Revitalizing the humanities: biocultures in the contact zone

The biocultures initiative asks us to get into the scrum and tangle with the significant scientific and medical issues of the day. This endeavor stands to revitalize the humanities. It does so not only by insisting on putting scientific endeavors in context, but also by rethinking humanistic inquiry itself, particularly how its findings are unique and potentially useful to those who are not by profession nor inclination humanists. Significantly, Jay argues that we must do this by coming forward "as experts in our own fields," not through a flattening of our interpretive acumen or a repackaging of our ideas to "the people." Policy contexts are, indeed, a good match for the kind of analyses we develop in literary and cultural study a attentive to detail and consequence, broadly descriptive but at the same time focused, our interpretive practices tend to take an example, develop an understanding of context, and make broader conclusions with suggestions for caution and specificity. These seem ideally suited to public policy.

In the case study example that Jay provides, current epigeneticists are confident that their support for directed evolution and the inheritance of acquired characteristics, based in "strong" data, will avoid eugenic tendencies and arguments for intelligent design, both construed as ideological overlays on scientific findings. These arguments seem to replicate the "good science" over "bad ideology" claims made in Toronto that I alluded to earlier. Literary analysis allows us to see the mutual and inevitable imbrication of science and ideology, such that the good and bad cannot be disaggregated from the mix so easily and assigned a stable meaning. As Jay points out, culture mediates the meaning of scientific findings in ways that scientists rarely control. The difficulty of separating science from ideology, beliefs grounded in "data" from utopian longings, is captured in Charlotte Perkins Gilman's Herland, another Neolamarckian text devoted to eugenics and presenting a feminist utopia simultaneously enabled and marred by its racist science. The modern history of biology is haunted by the "race problem" because it remains culturally unsolved, and vice versa a the modern history of culture is haunted by the "race problem" because race remains a biological puzzle, seemingly evident somatically but nonexistent in a genetic sense.

Finally, the biocultures paradigm suggests that the answer to "What's your data?" is neither the social construction of knowledge nor the idea of the text. Data is the selective information that we interpret as findings. All disciplines engage in this exercise, as Len suggests in the manifesto. The data themselves are facts, but they are not in themselves significant without interpretation. In literary analysis, reading produces data analyzed through the varied frameworks of criticism. Our expertise is in identifying, selecting, and interpreting the data of textual and discursive contexts, and linking these to broad cultural patterns, both historically and contemporaneously, as well as developing rich understandings of the complexity of linguistic significations.

In the language of my institution's former tag line a "putting [this] knowledge to work" a or, in its new brand a using it to "invent the future" a I want to advocate the serious challenge this expertise represents, especially to status quo humanities. Revitalizing the humanities through biocultures will only happen when we begin to believe that speaking beyond our own kind, and presenting our evidence for others, matters. Because we so often speak in forms of discourse meant only for our own kind (that is, decipherable only by other literature professors), I can only deduce that we do not think our contributions to knowledge make a difference outside our own, relatively enclosed, worlds of practice. As Jay made clear, the answer is not a dumbed down humanism but a willingness to engage with that expertise a its data, its interpretations, and its knowledge in the strongest sense a in the contact zone of public science policy.

Editor’s note: Those who don’t have access on-line to New Literary History will find a similar version of the biocultures manifesto at the biocultures website:
http://www.biocultures.org/index2.php?page=links

What Is Medical Humanities and Why?

January 25, 2008 at 11:25 am

Left and right brain function
Commentary by Jack Coulehan, M.D., M.P.H., Professor Emeritus of Preventive Medicine and Fellow, Center for Medical Humanities and Bioethics, Stony Brook University, New York

"Medical humanities" is one of those I-know-one-when-I-see-one terms. Taken literally, the two words have about the same level of specificity as would "medical sciences," which includes everything from biochemistry to pathology. No wonder our scientific colleagues press us to give a more precise definition or, even better, an accurate description of just what we are trying to accomplish in medical humanities curricula. Unfortunately, believers tend to assume that our colleagues might easily understand the importance of medical humanities, if only they opened their eyes and adopted a different paradigm. In my experience only underdogs and fuzzy thinkers ever talk about paradigms.

To me it's surprisingly difficult to say with any degree of clarity what medical humanities is. It certainly isn't the medically relevant content of allaor most, or for that matter, anyaof the traditional humanities disciplines. We don't engage literature, history, philosophy, anthropology, religion, and so forth in any substantive way. While we do, or should, teach bioethics content in some depth, medical humanities folks often recluse themselves from bioethics as such. Yes, we dabble in literature, and more generally, narrative. History plays a role and sometimes theater and film. But what else? Does humanities include communication skills? Or spirituality? And what about more traditional stuff like medical sociology?

Medical humanities relates to, but is not identical with, the art of medicine, for which nowadays we often use the word "doctoring." Doctoring requires communication skills, empathy, self-awareness, judgment, professionalism, and mastering the social and cultural context of personhood, illness, and health care. Learning doctoring includes a process of character formation that requires years of role modeling and guided practice. We base our claim for the importance of medical humanities on the assumption that our teaching contributes significantly to the development of doctoring skills. However, a moment's thought should tell us that physicians of the past must have learned these skills without studying such a discipline, and many continue to do so today. Thus, whatever medical humanities is, it's not a sine qua non for professional formation.

The claim that medical humanities curricula help our students become better doctors has another interesting aspect. Our use of the term "better" suggests a practical moral dimension, i.e. young physicians will care for their patients more effectively, if they study medical humanities. However, although humanities disciplines once counted moral education among their goals, they no longer do so. Today you don't study history or literature to become a better person. So, from an academic perspective we appear to be way off-base when we co-opt these disciplines for a practical moral goal not shared by their "mother" departments. This makes defining what we're doing even more confusing.

Despite all this, medical humanities feels right. As with any new field, it's full of enthusiastic advocates who aren't afraid of rocking the boat. At present medical education is a patched-up old hull that could sink at any time. Boat rockers are important to help convince the rest of us that we better get to the shipyard quickly and find ourselves a new model. I suspect that humanities educators who succeed at this do so because they are sensitive and thoughtful people who care passionately about medical education and not because they know a lot about philosophy or literature. Medical humanities also points the way toward remedial education in habits of the heart. Nowadays, our culture disvalues liberal education, is skeptical of virtue, and, in particular, glorifies self-aggrandizement over altruism. Thus, today's medical students usually lack a liberal education and often a belief in virtue. These factors make them more vulnerable to a culture of medicine that reinforces egoism, cynicism, and a sense of entitlement. Medical humanities (whatever it is) may assist students in resisting these negative forces by opening their hearts to empathy, respect, genuineness, self-awareness, and reflective practice. As John Gregory wrote, "A gentle and humane temper, so far from being inconsistent with vigor of mind, is its usual attendant; rough and blustering manners generally accompany a weak understanding and a mean soul…" 1

1.Gregory J. Lectures on the Duties and Qualifications of a Physician. London, W. Strahan and T. Cadell, 1772. Reprinted in McCullough LB (Ed.) John Gregory's Writings on Medical Ethics and Philosophy of Medicine, Dordrecht, Kluwer Academic Publishers, 1998, p. 182.

Medical Ethics on Stage

January 11, 2008 at 3:33 pm

Actors performing 'Don Guzman' to an audience of deaf-mutes using sign language. Wood engraving by G. Durand, 1877.

Commentary by Angela Belli, Ph.D. Professor of English, St. John's University, New York City

For those interested in the debates concerning ethical issues in biomedical science and technology, the domain to visit is the theater. Playwrights frequently focus on the conflict between human values and the rapidly changing technology that has come to prevail in the delivery of health care. They find in contemporary medicine a rich source of material. Current theatrical representations of medical discourse take their authority, language, images, and charactersaa whole roster of professionalsaall from medicine. A quick perusal of some of the most honored plays of our time reveals how the dramatic conflict, essential to the structure of the work, may be located in an ethical issue to gain the dramatist's attention.

End-of-life issues, including the termination of treatment, are presented in graphic terms in Brian Clark's Whose Life Is It Anyway? The question posed in the title is examined from three perspectives: medical, philosophical, and legal. The protagonist, Ken Harrison, is a hopelessly paralyzed young sculptor who is kept alive by mechanical means. Feeling that he has lost all personal and artistic freedom, he concludes that to continue him in such a state is to deny that which distinguishes him as a person. He is opposed by his attending physician who believes that if he allows Ken to die he will be aiding him in an act of suicide. The play turns on one issue: the goal of medical ethics. The resolution confirms the view that if a goal of medical ethics is the restoration of health and if therapy is inadequate to restore those functions that enable one to pursue one's spiritual goals, then medicine need not assume an aggressive role.

The Elephant Man by Bernard Pomerance presents a study of the need to uphold human dignity. Set in the Victorian Age, the play recalls the life of John Merrick, an actual individual who suffered from what is represented as neurofibromatosis. Severely disfigured he is shunned by society and regarded as a freak. Another view, "the medical gaze," is introduced when Merrick's condition comes to the attention of an idealistic young surgeon, Frederick Treves. Aware of the limitations of science to restore his patient to health, Treves undertakes a project in behavioral research, reconstructing a social context for Merrick. The play reaches its climax when the patient realizes that the life of normalcy and freedom created for him are illusory. Merrick's final triumph lies in his successful act to repossess the dignity he had been denied.

Margaret Edson's play W;T introduces a heroine whom the audience views during the last two hours of her life passed in a research hospital where she has been a participant in an experimental chemotherapy program. Issues regarding the treatment of the individual as research object give rise to the dramatic conflict, with the heroine confronting various staff members who are anxious to keep her alive for research purposes. In the conclusion of the drama, she regains mastery of her fate and her human will as she overrules the orders of the medical staff with a directive of her ownaher DNR request.

Another heroine who leads us to confront challenging ethical questions appears in Mark Medoff's Children of a Lesser God. The dramatic focus is on a young woman who has been deaf since birth. Questioning the attitudinal barriers erected by the social majority who fail to communicate with the afflicted and, consequently, conclude that the deaf are mentally inferior, she resists being marginalized and demoralized. Moreover, she insists on using sign language, her preferred means of communication. Choosing her own means of expression is essential to preserving her integrity. Along with the social model, the medical model is recognized in the play. Medicine's assessment considers the disability to be an illness requiring treatment. A form of intervention such as cochlear implants is frequently advocated. Ethical issues emerge as the varying views of disability give rise to the dramatic conflict.

In his brief, one-act drama The Sandbox, Edward Albee examines ageism, a pervasive canker in the social fabric that targets older individuals. The dramatist locates the bias within American society and spotlights the family structure as a likely site. Further, he examines the stereotype that links ageing with cognitive decline and leads to the erroneous conclusion that the elderly are of little value.

Michael Cristofer's The Shadow Box offers an artistic view of the philosophy of hospice care, which provides dying patients with an alternative to traditional, impersonal care provided by the established medical system. On stage the dramatist presents an assortment of patients, friends, and family who are torn between accepting a life that has been altered irrevocably for each or disallowing the reality they cannot escape. The drama reveals the value in affirming life and embracing the quality of the time that remains.

The dimensions and cultural ramifications of HIV/AIDS share galvanized discourses within medical, political, and artistic spheres. The theater provides its own sanctuary within which the public may consider the effects of a baffling disease that has shaken the security and confidence in biomedical advances. While constructing an illusory world, drama locates the dialogue in public space, providing a unique opportunity within a communal setting for raising awareness as it promulgates the facts and spurs socio/political action. One play to achieve such goals is Before It Hits Home by Cheryl West. The work recounts the dissolution of an African American family as it reacts to the unexpected crisis in its midst when a son is revealed to be infected.

In searching for valuable tools to encourage greater understanding and knowledge of bioethical dilemmas, one may consider placing copies of some good plays on the desks of medical students, alongside classical texts on medical ethics.

Note: All plays referred to above, except Children of a Lesser God, will appear in the forthcoming (2008) anthology, Bodies and Barriers: Dramas of Dis-Ease, edited by Angela Belli and part of the Literature and Medicine series at The Kent State University Press.

Further Reflections on Medical Humanities

December 22, 2007 at 3:32 pm

Left and right brain function
Commentary by Johanna Shapiro, Ph.D., Professor, Department of Family Medicine and Director, Program in Medical Humanities & Arts, University of California Irvine School of Medicine

 

The intriguing musings of Brian Dolan on this blog (Medical Humanities: Education or Entertainment?) and the incisive comment by Schuyler Henderson inevitably provoke further reflection on the medical humanities and what they are doing in medical education. I would like to add, somewhat discursively but I hope ultimately relevantly, to the discussion as follows.

In his inaugural speech as first president of the Czech Republic after the so-called Velvet Revolution brought about the downfall of communism, Vaclav Havel, also an internationally renowned poet, reflected on how new societies must be built. (1) He observed that everyone was looking toward the new government to tell them what to do, to lead them into a new way of living and a new way of being. But Havel claimed that the established political and institutional structures were unavoidably compromised, having been constructed during, and based on the assumptions and priorities of, the communist dictatorship. The people could not rely on existing bureaucracies and institutions - what already was - for guidance. Instead, they had no choice but to turn to each other. Stumbling and staggering, they would have to risk building a new world together.

Now I am not suggesting that the current medical education establishment is a communist regime; nor that medical humanities represent the voice of a people seeking liberation and freedom. Metaphor has its limits; and six years later, Havel acknowledged that although societies need to listen to poets as much as bankers or stockbrokers, the world cannot easily be transformed into a poem. (2) However, I do believe there are instructive implications to be gleaned from Havel's call to a populist-based rethinking of common assumptions in terms of ongoing debates about medical education and medical humanities.

Specifically, one of the things we learn from Havel's speech is that it is very difficult for any institutionalized power structure to change itself. The institution of medicine is deeply rooted in certain mechanistic, linear, positivist, objectivist, and reductive assumptions that are expressed every day in the ways physicians behave and the system as an entirety works; and which make it difficult to see the humanities as anything other than, at best, a nice but not essential, part of medical education; and at worst, pretty much a waste of time. Even if institutionalized medical education "makes room" for the humanities, it will do so on its own terms. This is not necessarily bad, but it is also not necessarily sufficient. As a particular instance of this difficulty in expanding its parameters, I will offer the example of "rigor" vs. "entertainment."

A pervasive criticism of the humanities among basic scientists and many clinicians as well is that they are a "soft" endeavor, a pursuit falling entirely outside the realm of science. The implication is that, therefore, they have little or no place within a scientifically-based profession such as medicine. The demand from the existing power structure of medical education is that the humanities justify themselves as a "rigorous" discipline; and many within the humanities are only too happy to attempt to comply.

Now, anyone who has sat through a course on postmodern literary theory should have no doubts that the approach taken by the academy to the humanities can be as intellectually rigorous as any course in biochemistry or pathophysiology. However, perhaps this is not the point, or at least not the most important point. No one would deny that one of the potential contributions of the humanities is to develop in its students the fostering of critical reasoning and judgment based on close observation of textual evidence and lucid argumentation in support of such. But is that the main reason the humanities are part of medical education?

We can discover one possible answer in Margaret Edson's play, Wit. (3) Here we see the fiercely intelligent scholar Vivian Bearing coming up against the limits of intellect in her struggle against ovarian cancer. It is not that her brilliance is irrelevant, but that it can carry her only so far in her journey toward death. What she needs at some point is compassion, empathy, nurturance, and caring (stereotypically embodied in the nurse Susie). The play in its entirety conveys the realization that intellect unaccompanied by love is lacking in the face of suffering and death.

How does this lesson pertain to the question facing teachers of medical humanities regarding the relevance of their discipline to medicine? One possibility is that we should not feel constrained to argue the issue solely on the grounds chosen by the medical education establishment. As outsiders in the culture of medicine, humanities scholars understandably feel the need to gain credibility and legitimacy. Also understandably, they believe that they can best do so by accommodating to this system's rules: e.g., set behavioral objectives, define skill sets, identify competencies, quantitatively measure impact. There is nothing terribly wrong with taking this approach. But I question whether following rules promulgated by the basic sciences adequately conveys the richness, complexity, and yes ineffability that the humanities have to offer medical students.

No one disputes that rigor, cognitive discipline, and the development of intellectual faculties should be stimulated at all levels of the academy, equally in biochemistry and in a class on pathography. But is intellectual rigor the only thing that matters in this debate? No one wants to water down their discipline, least of all "outsiders" accused of softness and marginality. Because humanities scholars in these settings are not training other humanities scholars, but physicians, the goals and emphases of their teaching must be different. To my mind, the issue is not dumbing-down or watering-down, but essentializing, focusing on the heart of the humanities that is of real value to the physician. This may be defined in part by "rigor," but as Wit suggests, it may be defined according to other criteria as well, if we choose to do so.

I do not think that, at this moment, we have agreement on what should comprise this essential humanities core. But it is clear to me at least that the great, unique power of the humanities lies in their capacity to engage the emotions as well as the intellect, to move the heart while provoking the mind. In this regard, the humanities are supremely relevant to the education of physicians, because this balance of intellectual steadiness and emotional tenderness (in the words of Jack Coulehan) is exactly what is required of them in every single clinical encounter. (4) Emotionally connecting with (as opposed to simply intellectually comprehending) issues of multiple perspectives, ambiguity, complexity, failure, suffering, commitment, and devotion (to mention only a few) cannot be avoided in medicine, and can only be learned through engagement with the humanities in some form or other.

And this brings us to Brian Dolan's speculations about "entertainment." Suppose medical students' exposure to the humanities is not always "rigorous"? Suppose it involves attending the above-referenced play Wit; or strolling through a museum; or writing a poem? Suppose the humanities do, at times, "entertain" their students? Who is to say that it is not through "entertainment" that equally important educational experiences can occur? We in medical education should be exquisitely aware of the power of the hidden curriculum, a curriculum that technically does not exist at all, yet shapes student attitudes and values more strongly than any formal course. (5) The method of delivery should be just that - a means to an end. It is because we are often not clear on what we really hope to achieve with our medical students in bringing them into with the humanities that we focus so obsessively on whether our teaching sufficiently conforms to the "rigorous" standards of other aspects of the curriculum.

Humanities are a way to teach people to think about, understand, be moved by and engage with the human condition. If we can accomplish this end, in ways that are rigorous, or entertaining, or both, we will be on the path to creating a new "society" of physicians, who look at patients and doctoring very differently than the present generation. In doing so, we cannot rely on the educational institutions in which we find ourselves, because they were created out of modernist, Flexnerian assumptions about the nature of health, illness, and medicine. We must rely on each other, on communities of individuals, comprised of humanities scholars, clinicians, and even basic scientists who share certain visions and aspirations for healthcare, and who are willing to risk teaching in ways that honor the full potentiality of the humanities in medical education.

References

1. Havel, V. New Year’s address to the nation. 1990.http://old.hrad.cz/president/Havel/speeches/1990/0101_uk.html

2. Havel, V. A farewell to politics. The New York Review of Books. 49:16, October 24, 2002. http://www.nybooks.com/articles/15750

3. Edson, M.. W;t. New York: Faber and Faber, 1999

Coulehan, J.L. Tenderness and steadiness: emotions in medical practice. Literature and Medicine. 14:222-36, 1995

Lempp, H. and Seale, C. the hidden curriculum in undergraduate medical education: qualitative study of medical students’ perception of teaching. British Medical Journal. 329:770-3, 2004

A Psychiatrist and a Poet

December 8, 2007 at 5:42 pm

Brain and Perception

Commentary by Ron Charach, M.D., Toronto psychiatrist, poet, and essayist.

To be both a psychiatrist and a poet is either a dual calling or a double whammy, depending on what you choose to emphasize. Such a medical/literary hybrid has surely won the sweepstakes in the personal sensitivity department. I am often asked whether being a psychiatrist helps me to be a better poet, though the reverse question is asked less frequently, especially since I don't do 'poetry therapy' in my psychotherapy practice. Before answering the question, a little more wordplay on the dual title may be in order.

One raises fewer eyebrows if one says "I'm a psychiatrist who also writes poetry" than if one says, "I'm a poet who does psychiatry on the side." The obvious difference in job security and monetary status of the two activities might lead to offbeat explanations like, "I couldn't make a living as a psychiatrist, so I went into poetry for the money" or, "Poetry is my day job, but I do psychiatry out of love."

There haven't been many psychiatrists/poets writing in English, at least not to the point of publishing (as opposed to self-publishing) several books. In the United States, people like Richard Berlin and Ronald Pies spring to my mind. A few others are represented in the anthologies of world physician poetry, Blood and Bone and Primary Care, published by the University of Iowa Press.

The late/great American poet Robert Lowell had a psychiatrist - er, actually, he had cause to visit his mother's psychiatrist, Merill Moore- a man who penned verse in what he nicknamed his 'sonnetarium'(oooh) at the back of his New England home. In other languages, Sweden's Tomas Transtomer, who had a psychology background, saw patients, and specialized in writing about people on the brink of doing something truly desperate, or at least, transformative.

I started writing in deadly earnest in pre-adolescence, and entered many essay and poetry-writing competitions, usually getting an honourable mention or placing second or third, which only whet my appetite to try harder. After being a psychiatrist for the past 27 years and psychotherapist for the past 30, I would say that practicing the craft has given me a good ear for dialogue and monologue, for how people actually talk and think. Dream analysis has also sensitized me to the value of using dreams as bridges to more fully understanding people’s fears, preoccupations and goals.

Psychiatrists from the past whose work informs my own include Freud, whose main prize, the Goethe Prize, was in literature, not medicine, and the late Heinz Kohut, whose nearly unreadable books nevertheless are rich in their appreciation of the powers of the literary imagination and very rich indeed in their conception of the needs of a viable self. I also get a lot of tips from more prosaic theorists like Aaron Beck, who invented cognitive therapy.

Being a poet informs my work as a psychiatrist insofar as both callings focus intensely on language and its many layers of meaning.The mind is hard-wired to make and to understand metaphor, something the neuroanatomists have only begun to study. Many of my poems are about medicine in general and psychotherapy in particular, and I would refer the reader to rather amusing if vaguely unsettling pieces on such procedures as "MRI" and "Colonoscopy", both poems written from the perspective of the wary physician/patient who 'knows too much'.

Anyone who would like to see the many subjects which a psychiatrist/poet might take on is invited to look at my latest book, Selected Portraits, published this autumn by Wolsak and Wynn, which contains poems about relationships from my first six collections.

I would offer a caveat for those who want to join me in the dual calling. Being a psychotherapist is especially hard on the back, given the relatively fixed postures one must sit in for large portions of the working day. Being a writer can also be hard on the back; ask Philip Roth who often works at a stand-up desk. Poets, of course, have it easier than novelists, but the physical issues add another form of double jeopardy to the work.

Psychiatrists and psychoanalysts are often talent manques, men and women who are reluctant to come out from behind their therapeutic neutrality. They get few opportunities to assert themselves as people with strong opinions and viewpoints, at least not in the consulting room, where to do so might be inappropriate. I work a lot with adolescents, who have ‘automatic shit detectors’ and tend to appreciate frankness. Knowing I am a poet, other physicians often send me referrals who are actors, screenplay writers, even the occasional poet.

The patients I write about are composite creations, actual patients sometimes serving as springboards for fictional portraits that may include auto-biographical takes on the poet and his own family. It might sound overly cautious, if not downright paranoid to state, at the end of a book of poetry which everyone knows to be a work of fiction, "No character in this book is identical to any living person", but I've often been tempted to do exactly that. In the end, though, I find the first-person-singular voice to be very effective and collar-grabbing and am usually willing to run the risk of the reader's deciding that the views presented in the poem are identical to that of its creator. Consider it the third hazard of this unique double calling.

Grey Land: Soldiers on War

November 22, 2007 at 3:53 pm

Soldier

Commentary by Barry M. Goldstein, M.D., Ph.D., Associate Professor of Medical Humanities at University of Rochester School of Medicine and Dentistry

In June and July of 2007, I spent a month in Iraq photographing and interviewing soldiers of the Army’s 2/69 Combined Arms Battalion of the 3rd Brigade Combat Team, 3rd Infantry Division. The visit was the culmination of a project intended to convey a sample of the variety of faces and voices of those who serve in our armed forces. I began the project with no political agenda, preferring to let the soldiers speak for themselves. You will find no more powerful an indictment of war than from an experienced professional soldier, nor a more eloquent enumeration of the reasons for serving.

The origins of the project began in New York City on September 11, 2001. Like many New Yorkers, I photographed the attacks and the city’s response in the days that followed. Subsequently, I undertook a project photographing and interviewing a group of New York University medical students who had volunteered to work in the medical examiner’s morgues helping to identify human remains. This was their first exposure to the results of extreme and deliberate violence, and it had a profound effect on them. This work was ultimately published in a collection called Being There (Master Scholars Press, 2005).

By the time Being There came out, the war in Iraq was well under way-a direct consequence of the events I’d witnessed of 9/11. There were parallels between the young medical students I’d worked with, and the young soldiers serving overseas. Soldiers train extensively for their work, take it very seriously, and may experience levels of violence that most of us scarcely imagine. But despite their uniform dress and appearance, soldiers are individuals, and have many of the same concerns, desires and problems as the rest of us. I wanted to learn more about those who’ve chosen this particularly demanding profession in post-9/11 America.

After a year of initial inquiries, I was fortunate enough to be introduced to members of the 2/69 Battalion of the 3rd Brigade Combat Team, 3rd Infantry Division, stationed at Ft. Benning (Georgia). My contact was (then) Lieutenant Colonel Kathy Platoni, Ph.D., a practicing psychologist and combat stress specialist with over 25 years of service. I made my first trip to Ft. Benning in April of 2006, only three months after the brigade’s return from Iraq. During much of that time, the approximately 400 soldiers of the battalion were deployed in Ar Ramadi, then the "seat of the insurgency" and home to a particularly violent form of urban warfare. As one soldier noted:

Ramadi taught me the true nature of war. I’d spent years studying waraits philosophy, rulesabut war is ugly, chaotic, confusing. Everyone gets hurt. No one survivesabecause you’re not the same afterwards. You experience the crushing depression of seeing someone you love die violentlyaand think that you’re responsible. A 24-year-old should not have to do that.

I subsequently made eight trips to Ft. Benning, photographing and interviewing members of the brigade, and, when possible, their families. I asked the soldiers about where they grew up and why they joined the military, about whatever experiences during their deployment they cared to share, and about the difficulties of maintaining a family life both during and after deployment. Again, my goal was to convey something about who these individuals are, via their own words.

In January of 2007, it became clear that the brigade would be re-deployed. I decided to finish the project with a visit to the 2/69 in Iraq. When I arrived at Forward Operating Base Rustamiyah on the eastern edge of Baghdad in mid- June, the battalion had been deployed for three months. This was the second deployment for over half of these soldiers, and the third deployment for many.

The battalion lost three men the day before I got there. I photographed and spoke with their company commander a week later, and realized something I hadn’t before, despite all of my interviews. He knew these men intimately-knew them more closely than family. When the rest of us suffer this kind of loss, we take time for ourselves. These folks don’t have the luxury of a day off. They have to go right back out the next day- usually performing two 4-6 hour patrols a day, under constant stress. The weather is extreme-between 110-120 deg F-and these men and woman carry over 60 lbs of gear and weaponry. I near about died every time I went out carrying just a helmet, body armor and a camera. I still don’t entirely know how they do it.

Our soldiers have to be warriors, politicians, civil engineers, judges, and anything else that’s called for in their particular area of operations. The issue as to what we’re doing there, or whether we’re being at all successful, is moot to these soldiers. They go where they’re sent, do what they’re told, and try and make the best possible job of it.

I feel an enormous sense of responsibility to the men and women who have shared their stories with me. My travel is finished, and I’m now faced with the hard part-editing several thousand photographs, and several hundred pages of transcribed interviews. The intent is to collect these in a book, tentatively titled Grey Land: Soldiers on War. The title comes from the poem "Dreamers" by the WWI soldier and poet Siegfried Sassoon:

Soldiers are citizens of death’s gray land,
Drawing no dividend from time’s to-morrows.
In the great hour of destiny they stand,
Each with his feuds, and jealousies, and sorrows.

You can see a slide show of Dr. Goldstein’s images from Iraq at www.bgoldstein.net/iraq. The show will start automatically, and takes about five minutes.