Lincoln in the Bardo in the Bardo/ by Russell Teagarden

April 5, 2017 at 11:36 am

Russell Teagarden is an Editor of the NYU Literature Arts and Medicine Database and helped lead the Medical Humanities elective at the School of Medicine this past winter. In this blog post, he experiments with creating a text collage from recent reviews of George Saunders novel, Lincoln in the Bardo.

Author's note:
George Saunders is well known for his inventive and affecting short stories. Lincoln in the Bardo is his first novel, and as described by Charles Baxter in his review in the April 20, 2017 issue of The New York Review of Books, it "doesn't resemble any of his previous books…nor does it really resemble anyone else's novel, present or past. In fact, I have never read anything like it." The story is told by a chorus of spirits or ghosts in a "bardo," which is a Tibetan limbo of a sort for souls transitioning from death to their next phase. Saunders rarely gives any individual spirit more than 2 or 3 lines of dialog, and he intersperses short snippets from historical texts- some real, some not-to provide contextual background. Of particular interest to the medical humanities community will be the focus on the well-trodden subject of grief through this experimental approach. The book has attracted the attention of many serious critics, so many in fact, that they can be assembled into a chorus to derive a review of the book in the book's format. I have thus taken excerpts from published reviews, most real, a few not, to produce a review that covers how the book is laid out (I), how the bardo works (II), how the story flows (III), and how it's critically received (IV) as can be told by a chorus of reviewers in a bardo of their own.

I.

The entire book seems to consist of nothing but epigraphs, which themselves turn out to be either historical sources (some real, some invented) or the chatter of spirits, indiscriminately mingling with one another. After a while, the reader begins to recognize the unique cadence of each spirit. The purposefully confusing form adds a disorientating but dramatic element to the book, and forces the reader to focus.
anon/ the economist, march 23, 2017

Readers with conservative tastes may (foolishly) be put off by the novel's formait is a kind of oral history, a collage built from a series of testimonies consisting of one line or three lines or a page and a half, some delivered by the novel's characters, some drawn from historical sources. The narrator is a curator, arranging disparate sources to assemble a linear story.
colson whitehead/ the new york times, february 9, 2017

The Lincoln of the title is not Abe but Willie, the president's 11-year-old son, who dies of typhoid just hours before the novel begins.AWillie may be the Lincoln in the bardo, but the bardo is really in Abe.
benedict jamison/ u.s. presidents in literature quarterly, spring, 2017

Lincoln in the Bardo is set in a Washington cemetery in 1862, amid the resident population of ghosts. Using a format that combines a playlike assemblage of voices alternating with chapters composed of quotations from historical sources, it depicts how the ghosts respond to the arrival of Willie Lincoln, the president's son, who died of typhoid at age 11.
laura miller/ slate, february 6, 2017

The cemetery is populated by a teeming horde of spiritsadead people who, for reasons that become an important part of the narrative, are unwilling to complete their journey to the afterlife and still hang around in or near their physical remains.
hari kunzru/ the guardian, march 8, 2017

The novel is told through their speeches, the narrative passing from hand to hand, mainly between a trio consisting of a young gay man who has killed himself after being rejected by his lover, an elderly reverend and a middle-aged printer who was killed in an accident before he could consummate his marriage to his young wife.
hari kunzru/ the guardian, march 8, 2017

Those voices, and Willie's, come to us in snatches, usually brief, little bursts of subjectivity and consciousness tumbling over one another, sometimes conversing, sometimes interrupting, squabbling, contradicting.
alex clark/ the guardian, march 5, 2017

The novel operates like a cross between a film script and an oral history, much of it narrated by two woebegone ghost pals.
tod wodicka/ the national, march 22, 2017

It moves from collages of quotes from historical documents and textbooks about Willie's death (some of which Saunders appears to have invented) to a riotously imagined story of the ghostly inhabitants of the graveyard.
alex preston/ the financial times, march 3, 2017

To deepen the novel and give it context, Saunders regularly interjects bits of history and reportage (some of which he has created)aanother layer of voices, as it were.
david ulan/ the los angeles times, february 9, 2017

Are the nonfiction excerpts from presidential historians, Lincoln biographers, Civil War chroniclersareal or fake? Who cares? Keep going, read the novel, Google later.
colson whitehead/ the new york times, february 9, 2017

It may take a few pages to get your footing, depending. The more limber won't be bothered.
colson whitehead/ the new york times, february 9, 2017

 

 

II.

 

When someone dies, Tibetan Buddhists believe that they enter the bardo of the time of death, in which they will either ascend towards nirvana, and be able to escape the cycle of action and suffering that characterizes human life on earth, or gradually fall back, through increasingly wild and scary hallucinations, until they are born again into a new body.
hari kunzru/ the guardian, march 8, 2017

The bardo is an element of Tibetan Buddhism, a way station between incarnations in which souls prepare themselves for their next life.
laura miller/ slate, february 6, 2017

It's in the nature of the bardo, which exists, in Tibetan Buddhism, as a kind of purgatory, a transitional space for souls that can't give up their former lives. All the characters here are trapped, prisoners of the past, "bellowing their stories into the doorway, until it as impossible to discern any individual voice amid the desperate chorus."
david ulin/ the los angeles times, february 9, 2017

Time and space in the bardo Saunders conjures are the same for its inhabitants as they were for them in their former earthly domains. This bardo restricts its inhabitants to the geographic area of their burial grounds they were buried in Georgetown and so their bardo is in Georgetown. They measure their time in the bardo in "years." I was expecting something more other worldly.
alexis leigh/ buddhism and literature, february, 2017

This is not a straightforwardly Tibetan bardo, in which souls are destined for release or rebirth. It is a sort of syncretic limbo which has much in common with the Catholic purgatory, and at one point we are treated to a Technicolor vision of judgment that seems to be drawn from popular 19th-century Protestantism, compounding the head-scratching theological complexity.
hari kunzru/ the guardian, march 8, 2017

This grey purgatorial state is the 'bardo' of the novel's title. It has little in common with the Buddhist concept of that name, which envisioned a sort of metempsychotic wormhole that connected successive cycles of rebirth. In Saunders's bardo, a Dantean contrapasso transforms the ghosts in accordance with the moral ailments that afflicted their lives.
robert baird/ london review of books, march 30, 2017

For non-Buddhists, it is a recognizable limbo, full of milling entities who for one reason or another will not take the next step of the journey. Like the ghosts we know from stories, they are tied to their former existences, trapped by an idea of themselves, and can't leave until they are ready.
colson whitehead/ the new york times, february 9, 2017

 

III.

 

Unfolding over one night in a graveyard not far from the White House, it tells a story that is, by turns, simple and complicated, tracing both a father's grief and its effect on the Republic he serves.
david ulin/ the los angeles times, february 9, 2017

His father, already beset by internal doubt and external uproar a year into the American civil war, was propelled by restless grief to walk the dark and stormy Georgetown cemetery where Willie's body lay.
alex clark/ the guardian, march 5, 2017

His presence upends the order of the cemetery. For one thing, "young ones are not meant to tarry" unburdened by a lifetime's accumulation of failures and regret, they usually pass over quickly. But a visit by his grieving father agitates the boy, as well as his graveyard neighbors.
colson whitehead/ the new york times, february 9, 2017

Willie, like other children, is expected to pass on quickly to the afterlife proper, instead of remaining in the cemetery, but because of his father's grief he is tempted to stay.
hari kunzru/ the guardian, march 8, 2017

The boy's ghost wishes to stay in the purgatory of the graveyard, desperate for a few last moments with his father.
alex preston/ the financial times, march 3, 2017

There is a touching trio of eldersanames deliberately written lower-case who take Willie under their wing: roger bevins iii, a young gay man covered in eyes; hans vollman, who lugs around a "tremendous member", having been taken ill while anticipating his marriage-bed; and the reverend everly thomas.
alex christophi/ the new humanist, march 9, 2017

When the ghosts find that they're able to pass into Lincoln's body as he sits in the mausoleum, the reader is suddenly privy to the president's thoughts, and the novel discovers new depths.
alex preston/ the financial times, march 3, 2017

The father must say goodbye to his son, the son must say goodbye to the father. Abraham Lincoln must stop being the father to a lost boy and assume his role as a father to a nation, one on the brink of cataclysm.
colson whitehead/ the new york times, february 9, 2017

Willie's mother, Mary Todd Lincoln, does not figure in this story much more than descriptions of her taking to her bed. This is about a father's grief.
teresa slominski/ chicago american, february 24, 2017

 

IV.

Lincoln in the Bardo is part-historical novel, part-carnivalesque phantasmagoria.
alex preston/ the financial times, march 3, 2017

Saunders' primary intention in the novel: to take these whirling and disparate voices miserly widows, violent grifters, drinkers, doting mothers, licentious young men, abused slaves (even in this realm cast into a less hospitable portion of the graveyard) and unite them in their common humanity.
alex clark/ the guardian, march 5, 2017

The polyphonic narrative of the spirits is interleaved with constellations of artfully arranged quotation from primary and secondary sources about Lincoln's life, which Saunders uses to show that observers can be unreliable about the motivations and mental state of the president, and that even such questions as whether the moon shone or not on a particular night can be distorted by memory.
hari kunzru/ the guardian, march 8, 2017

And they lend the story a choral dimension that turns Lincoln's personal grief into a meditation on the losses suffered by the nation during the Civil War, and the more universal heartbreak that is part of the human condition.
michiko kakutani/ the new york times, February 6, 2017

In Lincoln in the Bardo, the immense pathos of the father mourning his son, all the while burdened with affairs of state, gives these sections of the book a depth that isn't always there when Lincoln is off stage. The busy doings of the spirits are entertaining, and Saunders voices them with great virtuosity, but the tug of Lincoln's griefAis sometimes too strong for them not to feel like a distraction.
hari kunzru/ the guardian, march 8, 2017

In the midst of the Civil War, saying farewell to one son foreshadows all those impending farewells to sons, the hundreds of thousands of those who will fall in the battlefields. The stakes grow, from our heavenly vantage, for we are talking about not just the ghostly residents of a few acres, but the citizens of a nationain the graveyard's slaves and slavers, drunkards and priests, soldiers of doomed regiments, suicides and virgins, are assembled a country.
colson whitehead/ the new york times, february 9, 2017

Saunders presents Willie's death as a turning point for Lincolnawill he be able to move on from his grief, to draw on it as a source of strength in the battle ahead, or will it crush him, the acuity of his own loss meaning that he sees Willie in every dead soldier?
alex preston/ the financial times, march 3, 2017

One of the novel's conceits is that byAoccupying the same space, the spirits can experience a dissolution ofAinterpersonal boundaries, understanding and feeling sympathy for each other in a mystical way. It is hard to be specific without spoiling the plot, but Saunders uses this device to imply a cause for Lincoln's later signing of the emancipation proclamation, a move that seems glib and reductive, a blemish on a book that otherwise largely manages to avoid sentiment and cliche. This is a small quibble.
hari kunzru/ the guardian, march 8, 2017

A portrait of Lincoln is not the point of this novel…the book provides slightly hidden away, but still quite visible a form of instruction concerning acceptance and grief.
charles bbaxter/ the new york review of books, april 20, 2017

It's tempting to trace some sort of connection between Lincoln and the Bardo and the political climate in which it has been published, but to do so, I think, is to miss the point. Rather, its concerns are existential, metaphysical, even when politics enters the work.
david ulin/ the los angeles times, february 9, 2017

Saunders's beautifully realized portrait of Lincolnacaught at this hinge moment in time, in his own personal bardo, as it were that powers this book over its more static sections.
michiko kakutani/ the new york times, february 6, 2017

Life is chaos and history a story, and even the greatest of our leaders are merely humans, after all. The recognition sits at the center of "Lincoln in the Bardo," which is a book of singular grace and beauty, an inquiry into all the most important things: life and death, family and loss and loving, duty and perseverance in the face of excruciating circumstance.
david ulin/ the los angeles times, february 9, 2017

The supernatural chatter can grow tedious at timesathe novel would have benefited immensely from some judicious pruning.
michiko kakutani/ the new york times, february 6, 2017

The novel is funny, poignant, and smart. But it's not an escape, just like it's not really about history.
theodore yurevitch/ the southeast review, february 21, 2017

This is a novel that's so intimate and human, so profound, that it seems like an act of grace.
alex preston/ the financial times, march 3, 2017

…………………………………………

Lincoln in the Bardo | 360 VR Video | The New York Times

 

Reading Lolita in Residency

March 23, 2017 at 11:23 am

Howard Trachtman, MD
Department of Pediatrics
NYU School of Medicine

Throughout history, reading books has often been viewed with deep suspicion by figures in authority. The Dominican priest Girolamo Savonarola collected and publically burned thousands of objects including books on February 7, 1497 in Florence, Italy, an infamous episode that has been recorded as the Bonfire of the Vanities. The books were condemned as temptations to sin. Russian dissidents put their lives on the line to gain access to books smuggled in from the West because they had been banned by the Communist politburo during the height of the Cold War. People have been imprisoned in Iran for reading Lolita. All high school students are familiar with Ray Bradbury's novel Fahrenheit 451, a science fiction novel that depicts a futuristic American society in which books are outlawed and "firemen" are authorized to seize and burn any book judged to be subversive. So even though reading books by the beach on a warm summer day is considered an innocuous activity, there is more to it than meet's the casual eye. It can be an act of great power.

 

One year ago, we started a reading group open to all the pediatric residents at NYU devoted to reading and discussing works of fiction. The selection process is open and consensus-driven, not particularly radical. We are receptive to non-fiction books but we have agreed to avoid literature expressly addressing medical problems or topics. The objective is to pick books that are high-quality literature. We are partial to books that are multi-dimensional and timely, expecting that they will push boundaries and stimulate thoughtful discussion. The senior member of the group prepares questions and gets the discussion started but no one has to raise their hand to speak. It quickly gets lively. We have read short stories by Edith Pearlman and novels by Jenny Offill, Kate Walbert, Kazuo Ishiguro, Edna O'Brien, and Ben Fountain.

Ms. Walbert joined the group for the discussion of her book, AA Short History of Women The books, which have been modest in length so we can finish them in time, have often been honored on lists of Best Books of the Year or Notable Books.
We meet bimonthly in the home of one of the faculty members and have a light dinner and desserts as we sit around in a tight circle to discuss the book. In part, we do this because it is worthwhile to find a friendly place outside the day-to-day hospital environment and away from the bustle of patient care for the group to get together. It is conceivable that it fosters a samizdat atmosphere among us. We can imagine that we are taking part in something that is outside the box, an underground activity that is a bit revolutionary compared to our day job as pediatricians. But apartments across the street from the Metropolitan Museum of Art are not hotbeds of revolution. If that is the case, where is the subversive element?

For starters, we read a book in hand. The Department of Pediatrics purchases the books and a hard copy is distributed to whoever wants to attend the group. No one brings a Kindle or reading device. Moreover, no one gets by reading a capsule summary or abstract of the book. We read the book from start to finish. This is a distinctly uncommon behavior in an age when most people routinely get their information online in easily accessible, abbreviated formats that can be easily read and digested. It may be considered a quiet act of rebellion when we show that an author's work deserves to be read and considered as a whole entity when we devote time and effort to understand what the author has in her or his mind.

Second, for attendings to see residents as more than a means to patient care and for residents to see attendings as more than the people who give orders and occasionally teach upsets the normal view of the residency ecosystem. The reading fosters a sense of community, a feeling that everyone in the department of pediatrics is a person with an interesting life outside the walls of the clinic or hospital. Each member of the reading group brings a unique perspective to the discussion that is worth listening to and taking into consideration. There is genuine camaraderie and free exchange of ideas between people who have usually kept apart in the hospital. We plan to open the reading group to more interested faculty because we think it promotes a type of interaction that is difficult to foster during rounds and provision of care. Instead of a hierarchical structure, the reading group promotes the revolutionary idea that residents and attendings share a common goal and can work together to achieve it.

Third, with the growing emphasis on evidence-based medicine, there is a worrisome tendency to think that everything worth knowing can be found within the pages of high-impact-factor medical journals. There is nothing to be gained or worth spending time on besides up-to-date summaries of validated clinical guidelines. Acknowledging that reading quality literature adds to one's knowledge and is time well spent goes against the grain of current residency training. There are many medical schools that have incorporated an appreciation of literature and narrative structure into patient care. These programs link medicine and the humanities and represent a welcome addition to the medical school curriculum. But they are pragmatic and primarily aim to help the residents become better doctors. Our reading group is designed to make reading good literature a worthwhile aim on its own merits, a distinctly different valuation for most residents.

Finally, it opens the possibility that reading good books can make residents better people. In a recent profile of Martha Nussbaum (New Yorker, July 25, 2016, 34-43), Rachel Aviv refers to a lecture in which Nussbaum writes that we become merciful when we behave as the "concerned reader of a novel," understanding each person's life as a "complex narrative of human effort in a world full of obstacles." The direction of Nussbaum's thought is from people to a literary mindset. The unspoken mission statement of the reading group is that Nussbaum's assertion can be made in reverse, namely, that a devoted reader of literature will become a more compassionate individual. Those who have chosen a career in the humanities have always known that the ultimate purpose of their study is to become better human beings. Physicians may have forgotten that charge in the struggle to become good doctors. Reminding them of the value of reading novels in residency may be disorienting at first. But we are optimistic. We meet and read together in the hope that introducing reading into residency will help trainees and faculty become better people. If the reading group makes us better doctors, we will take it.
If you have read this far, we want to reassure you that we do not take ourselves too seriously. We have a good sense of humor and have mostly enjoyed our careers so far in pediatrics. But we think we are on to something, a simple thing that may make any residency program a bit stronger and more meaningful for faculty and trainees. As Arlo Guthrie sang in Alice’s Restaurant if one or two residency programs start a reading group they may be considered sick or weird.

If three programs do it, the accreditation boards may think it is an organization. If fifty programs do it, it might become a movement. So go out with some resident friends, buy a book, and get together to talk about it. It is not as dangerous as it sounds.

ACKNOWLEDGEMENTS
We thank the leadership of the Department of Pediatrics for supporting the reading group.
We thank Lolly Bak for her thoughtful comments and suggestions about the essay.

PARTICIPANTS
Denis Chang, Deanna Chieco, Svetlana Dani, Patricia Davenport, Jasmine Gadhavi, Michael Goonan, Shelly Joseph, Sabina Khan, Marissa Lipton, Kira Mascho, Bridget Messina, Mary Jo Messito, Claire Miller, Shira Novack, Roshni Patel, Gabriel Robbins, Jessie Zhao.

 

 

Learning Empathy through Chekhov

July 26, 2016 at 3:26 pm

Guy Glass, MD, MFA, Clinical Assistant Professor
Center for Medical Humanities, Compassionate Care and Bioethics
Stony Brook School of Medicine

I am a psychiatrist who writes plays and has several professional productions and published plays to my credit. Having recently earned an MFA in theater from Stony Brook University, I am now affiliated with the Center for Medical Humanities, Compassionate Care and Bioethics at Stony Brook University School of Medicine. At both Stony Brook, and starting this fall at Drexel, I teach an elective entitled "Theater and the Experience of Illness" in which medical students both read plays and write their own dramatic monologues.

I dedicated my master's thesis to finding ways that plays might be used in medical education. This involved creating dramatic adaptations of two of Chekhov's "doctor" short stories, including "A Doctor's Visit." In April 2016, I was invited to bring "A Doctor's Visit" to the Arts and Health Humanities Conference in Cleveland. There, I was fortunate to have the opportunity to create a piece of theater with five medical students who happen to be very fine actors and who contributed the blog post below. I'm delighted to see that the exercise gave the students insight into what the arts can contribute to medical training. Moving forward, I hope to find other institutions that will allow me to bring this program to their students.

Reflections on the Importance of Dramatic Arts in Medical School Curricula

Alicia Stallings, DaShawn Hickman, and Nick Szoko

clevelandclinicIntroduction

As a part of the Medical Humanities conference held at the Cleveland Clinic on April 9th, 2016, we were asked to perform a dramatic reading of an adapted short story by Anton Chekhov entitled, "A Doctor's Visit." The piece, thoughtfully developed by Guy Glass, MD, MFA, takes place in a factory town outside of Moscow in the 1890s. It features a diverse group of characters: Dr. Korolyov, a middle-aged physician working to jumpstart his struggling practice; Boris, his eager apprentice; Christina Dmitryevna, a caricaturized spinster; Liza, a seemingly spoiled heiress; and Madame Lyalikov, Liza's frenetic and overbearing mother. The story centers on the encounter between Dr. Korolyov/Boris and the inhabitants of the Lyalikov mansion. Dr. Korolyov is called upon to tend to the needs of Liza. Motivated by the prospect of compensation, Dr. Korolyov and Boris make their way to a gritty industrial town outside of Moscow where the gaudy mansion is situated. They arrive to find a hysterical young woman, Liza, nearly bed-bound for no apparent reason. Initially, Dr. Korolyov operates in a detached, business-like manner when examining and interacting with Liza. He is eager to perform his duties and exit, having excluded any true disease process; however, when Madame Lyalikov invites Korolyov and Boris to spend the night at the mansion, Dr. Korolyov achieves a moment of profound insight when he stands in the property's garden and gazes at the glowing factory lights beyond. In this setting, Korolyov recognizes his lack of compassion and revisits Liza in her room, finally able to connect with the young woman and "cure" her by acknowledging and validating her unique narrative. In reading, rehearsing, and performing this work, we extracted three important themes: empathy, justice, and professionalism.

 

hickmanJustice, as told from the perspective of Boris (DaShawn)
Case Western Reserve University School of Medicine

At the start of the play, Boris attempts to wake the doctor, but we quickly learn that Korolyov would rather the student learn more of the basic science and medicine on his own. He is told to "memorize all the books on my bookshelf, dissect all the rats and frogs you can find. And come back at noon." As outrageous as this sounds coming from the doctor, many schools have taken to this self-directed learning style. Students are spending more time reading and learning on their own or in groups than with professors during their first two years of medical school. The play also makes it abundantly clear that although students need patients to learn from, patients are not always as willing to allow students to learn from them. One of the characters in the play, Christina Dmitryevna, bans Boris from seeing the patient with his teacher. She expresses how she is displeased to be "running a medical school." Being able to act in this role allowed me appreciate all the time I am able to spend with patients during my formative years as a student doctor.

Although the doctor doesn't appear interested in directly teaching Boris basic sciences, he does take the time to teach him about communication skills, history, and society, all topics that will have an impact on the quality of doctor that Boris will become. A theme that emerges from interactions between Dr. Korolyov and Boris is justice. As the doctor and Boris travel away from Moscow to the industrial town, the socioeconomic disparities become more pronounced. The doctor teaches Boris how poor and hard-working the factory workers are. He tells Boris that even though they are poor like the factory workers, because they are doctors, and thus in a higher social class, "[the factory workers] will always hate us."

The town is covered in soot from the factory, and so many people have health problems, including the limited life expectancy of 35. Despite this, the doctor lectures, "it is a pampered rich girl we have been asked to care for." Dr. Martin Luther King, Jr. summed up his teachings nicely when he stated "Of all the forms of inequality, injustice in health care is the most shocking and inhumane." The doctor not only points these injustices out to the student but challenges them in front of the student. He asks about the well-being of the factory workers and implies that it is subpar to the wealthy he has come to visit. These are bold actions that not only teach Boris to recognize injustices but to confront and work to dismantle them.

Without future doctors being taught these lessons the injustices that exist today will continue to permeate our healthcare system, stifling advancements in this realm for the betterment of mankind overall.

 

Professionalism, as told from the perspective of Madame Lyalikov (Alicia)
Cleveland Clinic Lerner College of Medicine

In the reading, I portrayed Madame Lyalikov, the mother of the patient in the play. In this role, I found that many principles of professionalism were highlighted during the preparation and enactment of the dramatic reading. One component that stands out was the principle of responsibility to colleagues. During my preparation for the role, it gradually became clear to me how different I was from the character. I could not relate to her in her stage of life (I am not a mother), nor her walk of life (I am not wealthy), nor her personality/disposition (I am neither of the anxious variety nor passive). Yet, despite my lack of similarity to this character, for the sake of the audience, to learn from the play, and for the sake of my fellow student-actors, so that they could also portray their characters well, I needed to work to understand this characteraher perspective and her mindsetato meet my responsibility to the group.

Principles of professionalism specific to the practice of medicine were also highlighted in the play. Most notably, the issue of bias was an important theme, which was illustrated by Dr. Korolyov's negative comments to the student about the patient and her mother. In my role as Madame Lyalkiov, I had an interesting vantage point, being both privy to Dr. Korolyov's bias, as an actor, as well as the object of his prejudice, as the character. In this unique position, I found myself reflecting: is Korolyov aware of his prejudice towards her and her daughter? Can she feel how he feels about them? Does she feel that his prejudice is impacting his care of her daughter? Is his prejudice hurtful to her? It was very interesting to reflect on these questions from the vantage point of a future healthcare professional. One likes to think that her attitude towards others can be isolated from how she treats them, and that one can even hide their prejudice, so that the other party is not aware. However, is this true? Are we as medical professionals, and as people in society at large, able to separate how we feel about others from how we treat them? And perhaps more importantly, if how we feel about them is based in prejudice (as in the case of Dr. Korolyov), is it acceptable to continue to harbor these biases, even if we think we can separate them from how we treat patients? These are important questions for students to consider as move forward in their development as medical professionals. My role as Madame Lyalikov brought these questions to the forefront, and gave me much to reflect on with regards to professionalism in interacting with and caring for patients.

 

Empathy, as told from the perspective of Dr. Korolyov (Nick)
Cleveland Clinic Lerner College of Medicine

"You will learn, if you are to be a doctor, you do not always have to do a thing." As Dr. Korolyov prepares to depart from his visit at the lavish Lyalikov mansion, he offers these reflections to his young assistant, Boris. As medical students, the words of Dr. Korolyov surely resonate with us. We embrace ignorance, thrive in discomfort, and accept inaction. We feel dually limited and protected by our positions as trainees. We are told that the greatest gifts we can give our patients are not medical expertise or surgical acumen, but rather our time, humility, and empathy. So what happens when these fail?

It is no secret that the ability of medical professionals to empathize declines over time. We are cautioned from the first day of medical school regarding this well-cited trend. When we examine Korolyov, we see the familiar vices of the burned out physician. His initial motivation to visit the Lyalikovs is financial. He forms a prejudgement of his patient based on socioeconomic class and lets this guide his diagnostics. There is an unspoken aroma of efficiency and industriousness that hovers over the encounter. As medical students, we face a similar climate. Our attitude towards learning and career choice is tinted by the haze of student debt. We train in tertiary care centers that venerate evidence-based medicine and cost-conscious care. We aim for concision and efficiency in our interviews and presentations. Amidst this, we strive to temper our own arrogance so as not to become hardened to the pain of those around us. With each day we spend on the wards, we are tempted to limit our vulnerability and minimize our emotional presence so as not to compound physical exhaustion with psychological. We ask ourselves, "Am I becoming a professional?" or, "Am I losing my humanity?" We become less of Boris and more of Korolyov.

For Korolyov, it takes a revelation, an "Aha!" moment to arrive at the proper diagnosis. Indeed, it is not until his liminal experience in the garden that Korolyov finally overcomes his psychological barriers to connect with his patient, recognize his biases, and act as a healer. Romanticizing such transformative moments is not unfamiliar in our profession. Our attendings often recall patient encounters that made them stop, reflect, and even reform. As medical students, we remember our first patient death, the first child we delivered, or our first "thank you." These moments, though rare, do more than just provide subtext for television dramas or ignition for research funding campaigns. In some ways, these instances and the act of recounting them eternally bind us to the humanism of our craft while allowing us to mature in our profession. Storytelling, whether it by play, article, or interview, remains powerful, not only for those who listen, but also for those who share. In reliving these experiences, we evoke our emotional self, and this is often done from a place of greater experience and wisdom. The value of this exercise cannot be understated, because beyond connecting us to the ethereal concept of "emotion," it allows us to reflect, critically and honestly, about how this experience and others like it have shaped our practice today. By participating in a dramatic reading of "A Doctor's Visit," I told a story that, over time, became my own. This opportunity offered a space for vulnerability and introspection, and I am thankful that I could engage in this dialogue alongside my colleagues.

Conclusions

For many students entering medical school, it has likely been years since they have taken part in a traditional stage play. Although many may have participated in variety shows or other short dramatic works in college, these dramatic engagements are notably different from traditional plays. The content of variety shows is written by the students themselves, and therefore generally presents contemporary issues from contemporary lens using contemporary language (most of which are shared by and native to the students). Other works of drama present the opportunity to explore diverse settings, subject matter, and perspectives. Utilization of selected plays and short scripts as teaching tools for individual students as well as groups of students has great potential. Indeed, for many medical students, there is great power in silencing our own voice to fully walk in the shoes of another and experiencing the world from their eyes. Script readings can offer students an opportunity to do so again, while providing a reminder why it is important to do so in life as well.

Other members include:
Anne Runkle and Megan Morisada, Cleveland Clinic Lerner College of Medicine.

The Patient Experience Book Club at NYU Langone Medical Center

March 2, 2016 at 1:41 pm

Untitled
When an AP reporter called to tell Erika Goldman, publisher of the Bellevue Literary Press, that its novel, Tinkers, by Paul Harding, won the 2010 Pulitzer Prize for fiction, "it was akin to receiving a blow to the head," she said. "It was concussive." For the first time since 1981, a book published by a small press won the award.

Ms. Goldman told this story to the members of the Patient Experience Book Club at NYU Langone Medical Center, a group that includes physicians, nurses, administrators, analysts and social workers among others. On a recent Friday afternoon, the group met to discuss Tinkers.

Tinkers recounts the last days of George Crosby. Lying in a hospital bed in the middle of his living room, surrounded by the members of his extended family, George's thoughts drift between the scene around him and memories of his boyhood. His father, Howard, a peddler of home goods in rural Maine, had epilepsy. Faced with the possibility that he would be committed to a psychiatric hospital Howard Crosby abandons the family leaving George, his mother and siblings to fend for themselves.

Time is a thematic thread running through the novel (George repairs clocks) as the narrative flows between memories of his childhood and his adult life. Harding describes his book as unlineated poetry. Its rich, descriptive language requires readers to settle into the prose, avoid distractions, and allow themselves the space to fully experience the story.

After a brief introduction by Ms. Goldman about how the Pulitzer Prize process works, the group turned to a discussion of the text. Their interpretations were filtered through their individual experiences working with patients and families. A social worker compared some "not so great" deaths she has witnessed to George's death at home with his family. A neurology administrator pointed out that the stigma attached to epilepsy remains a problem for some of the patients she encounters. Tinkers draws attention to the silence surrounding illness, another commented.

Untitled3

The Patient Experience Book Club was started by Dr. Katherine Hochman in 2012. She came up with the idea after attending a conference on patient experience that was organized by the Institute for Healthcare Improvement in Boston: "What I took away from that was in order to have an engaged patient, we need to have an engaged staff." She decided to hold meetings every two months to discuss books that related, even tangentially, to patient care. A small grant funds box lunches and copies of the selections. The books are made available in advance of the meeting. Sessions typically draw from 10-30 people from all areas of the medical center. For many, it's a chance to meet co-workers who they do not interact with in their normal daily routines.

Locksley Dyce, a hospital administrator, loves to read and is a regular attendee: "It affords me the opportunity to meet in a multi-disciplinary group and exchange thoughts with healthcare professionals whom I probably would not meet otherwise."

The Club invites a faculty or staff member with expertise in a particular area to lead the sessions. Dr. Joseph Lowy from the palliative care service led the discussion of Being Mortal by Atul Gawande. David Oshinsky discussed his book Polio. And during the Ebola scare, the novel Blindness prompted a discussion of what it would be like for a whole society to be affected by an illness. During that session, Hochman and the group wore blindfolds to experience blindness for themselves.

Untitled2

Mr. Dyce finds the sessions particularly thought-provoking. "We try to apply the material from the book to healthcare - especially patient care - and the individual roles that we play in it," he said.

As the session on Tinkers drew to a close, and the members prepared to go back to work, ordering tests, analyzing metrics and attending to their patients, they reflect on the issues brought up in the meeting and acknowledge the importance of taking time to connect with their patients.

The group meets next in April to discuss When Breath Becomes Air by Paul Kalanithi.

English Departments and Healthcare

May 5, 2010 at 12:05 pm

Commentary by Bernice L. Hausman, Ph.D., Professor, Department of English; coordinator of the undergraduate minor in Medicine and Society, Virginia Tech.

In answer to a listserv question about how professors of English might benefit from interaction with health care professionals:

I think one real benefit is widening the range of impact for English studies. Even our English majors can sometimes not see the importance of their knowledge and their competencies in the larger world, and often we can only suggest to the best of them that they go to graduate school to become like us. But undergraduates in English who are educated in the medical humanities begin to see places for themselves in the policy world, in public health, and in other careers in health care. That is one specific tangible benefit.

Another benefit is widening our own sense of efficacy as faculty. We have much to offer in terms of interpreting medical discourses in the contemporary world. Susan Sontag first noted in 1977 that all experiences of cancer are metaphorized into "fights" or "battles." That terminology rages on, and impacts cultural and medical thinking and practice about cancer. Our engagement with these issues and dissemination of our ideas in the public sphere is important, and it is an often neglected element of our scholarly practice. Engagement with physicians is one place to start.

Finally, we can benefit from collaborative funding endeavors. I am currently leading a research group studying discourses of vaccine refusal. As head of a multimodal team that includes faculty (humanities and public health), graduate students, and undergraduates, I find the research synergies energizing. In addition, we are going to submit a funding proposal to the NIH or CDC concerning the social and cultural contexts of vaccine refusal. Working with physicians and other health care professionals would only strengthen our proposal. Such research projects are intellectually and socially valuable, and can potentially bring in much needed funds to humanities departments increasingly strapped for operating funds and graduate student stipends.

The "Parallel 'Parallel Chart'"

March 8, 2010 at 5:58 pm

an illustration of hands reaching outCommentary by Hedy S. Wald, Ph.D., Clinical Assistant Professor of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI

May, 2006. We treated our Doctoring small group to a nice home-cooked meal to celebrate the conclusion of their first year of medical school-eight students, two lucky teachers. Students, after all, are hungry for knowledge but they're also hungry. We had grown to know these now 25% doctors through didactic but more so through their reflective narratives that we were privileged to receive and respond to…After dessert, I surprised each of them with a personalized binder of all their narratives plus the written feedback they had received over the course of the year from their co-teachers-Hedy (me), a clinical psychologist and Steve, a family physician. The teachers lugged home extra large binders with all the students' writings and feedback, precious cargo indeed. I hoped the students would hold onto the experience, maybe even look back one day upon those texts, tangible evidence of their metamorphosis. I got choked up that evening. With good reason.

It is a mysterious process, this reading and responding with written individualized feedback to students’ reflective narratives as we accompany them on their journey of personal and professional identity development. Rita Charon captured the awe: "What a remarkable obligation toward another human being is enclosed in the act of reading or listening" (1, p.53) This became my mantra as I diligently typed at my computer, striving to craft meaningful, quality feedback to the students’ narratives that had sailed across cyberspace to land on my screen. I tried hard to establish a "comfort zone", a trusting "mentor" relationship where an embryo doc could safely share vulnerabilities and uncertainties, personal angst and yes, triumphs, dramatic moments and perhaps even more meaningfully, everyday moments of caring that should be recognized by a self-aware, mindful practitioner (student and teacher alike). And, I learned, it wasn't a bad idea to keep "oven mitts" (2) nearby for the "hot" stuff, the personal and/or professional content that can be challenging for both writer and reader, albeit less frequently encountered. Life is not sanitized, homogenized, or neatly packaged. Neither are narratives.

Interactive Reflective Writing

Some background. Several years ago, Warren Alpert Medical School of Brown University (Alpert Med) included an interactive reflective writing innovation within their Doctoring course (3) for first and second year students; the current curriculum includes this as well. I was there from the get-go. Students send confidential "field notes" by email throughout the year- in response to structured narrative prompts on patient encounters and other topics-and receive written feedback from an interdisciplinary team. Early on, I sensed something special unfolding…Narrative medicine enthusiasts will not be surprised to hear about the perceived benefits of hearing a student’s voice within narrative (valued as distinct from the usual group dynamic), witnessing the representation of their experience in the written word to give it meaning, and deepening learners' reflective capacity through this process. "Clinicians donate themselves as meaning-making vessels to the patient who tells of his or her situation", Charon observed (1, p.132)…And the embodiment of this? The meaning-making vessel of narrative. Written feedback, I would suggest, is potentially a "meaning-making vessel" in its own right. Indeed, the "interactive" nature of this paradigm has pedagogic value, students have noted, as they appreciate writing with an "audience" in mind. (4) Narratively humbling indeed for those in that audience. (5)

Narrative content in a longitudinal context, Steve and I noticed, documented our students’ learning journey. But what of the teachers, the "seasoned travelers"? (6) It’s not about us, it’s about them (our learners). I know this. But maybe, just maybe, it’s about us too. Narrative connects on so many levels. We know this. It reminds us, inspires us, nourishes us. Students’ revelations within confidential interactive reflective writing can have a powerful impact, touching one’s heart and soul. Through authentic engagement, I found that their writings about clinical encounters (including personal and professional issues) served as narrative triggers for my associations. I experienced a flow, sometimes tidal wave of cognitive and affective responses, personal and clinical recollections, a potential treasure trove to share. Yet I would not share it all; educational responsibility prevails, judgments need to be made, and students don't want to read novels on their narratives anyway. Ultimately, something about this experience resonated with a key concept I had learned in narrative medicine: the "parallel chart" teaching tool, (1) inviting further contemplation.

Rita Charon appreciated the value of considering the nuance and texture of patients' experiences of illness as well as what students themselves were undergoing in providing patient care, even though "you cannot write that in the hospital chart, we will not let you". (1, p.156) "And yet", she instructed clerkship students (and later, residents as well), "it has to be written somewhere. You write it in the parallel chart" (1, p.156) In similar fashion, I suggest, the teacher's experience of the student's narrative, of the student's "narrative writing in the service of the care of a particular patient" (1, p.157) can be considered a "parallel 'parallel chart'". In essence, my narrative writing evoked by the student's text is in "the service of the care of a particular student", regardless of whether all of it or none of it appears in my formal written feedback.

The Teacher's Experience

What of this living organism, this "parallel 'parallel chart'"? Might it offer opportunities for a parallel process of transformative growth of a teacher? Let the student's narrative "brew". (7) Allow the narrative to speak to us, guide us, enhance our awareness, then trust our instincts, use our curiosity, and sift through our "parallel 'parallel chart'" to craft feedback of substance and worth…all in the service of the student, yet with mutual benefit. Let the teacher's narrative "brew" too. Professor Lee Jacobus' observation that "time moves on once the book is gone from the writer's hand and the writer is no longer the person who wrote the book" is germane (blog review of Margaret Atwood's Negotiating With the Dead: A Writer on Writing). (8) The student is no longer the person who wrote the reflective narrative; neither, I would assert, is the teacher who responded to it. It's called Education. And it gives "faculty development" a whole new meaning. The intersubjective process of transformative growth (1), I now realize, is not the student’s sole proprietorship. (9)

So we sift, filter, craft, and mold our "parallel 'parallel chart'" for most effective educational impact. My research colleagues at Alpert Med (Drs. Reis, Monroe, and Borkan) and I recently offered the BEGAN tool, the Brown Educational Guide to the Analysis of Narrative to help guide faculty with this process, describing integration of personal and clinical experiences, reflection-inviting questions, elements of close reading, as well as student text quotes within written feedback to students' narratives. (10) Be a "generous listener" (11) but more than that, use that "parallel 'parallel chart'" to support and challenge the learner toward deeper reflection, understanding, and meaning making. Oh, and be sure to pause before hitting the SEND button, we advise, to avoid foot in mouth disease and other such maladies.

Concluding Reflections

The literature is replete with explorations of what doctors find meaningful about their work, what it is that sustains them-making a difference in someone's (the patient's) life is often mentioned. (12) Within medical education, connecting to students through their narratives about connecting with patients can help make a difference in students' lives and our own. "Learn from every patient", the teacher teaches the student. "Learn from every student", the narrative teaches the teacher. And we do. Impressed with the power of narrative, a primary care doc, for example, recently remarked to me that reading and responding to students' narratives was helping remind him why he went into this business. As for me, I've grown as a teacher, colleague, and writer. Teacher me now routinely uses my "parallel 'parallel chart'" (with deepened insights) and BEGAN tool to craft what I hope is useful, meaningful individualized feedback to reflective narratives in the Alpert Med family medicine clerkship. My colleague self "ping-pongs" ideas (based on my response flow) with co-facilitators within small group teaching and with research colleagues, sparking creative output. I'm also fortunate to be able to reflect on their written feedback to students derived from their own "parallel 'parallel charts'". As a writer, narrative flow has led to gratifying creative and academic writing accomplishments; JAMA, Newsweek, Academic Medicine, and more. Correlation does not imply causation, but it sure feels that way. It's been a remarkable journey.

I ran into one of my original first-year Doctoring course students recently at an Alpert Med seminar. He looked good, more polished and self-assured, excited about Match Day in March, he told me. We took a moment to reminisce about the "good ol' days" of Doctoring and my, how time had flown. "I still have the binder", he grinned as he walked away and made my day. "So do I", I whispered, "So do I".

References

1. Charon, R. Narrative medicine - honoring the stories of illness. New York: Oxford University Press, 2006.

2. Ellis, K. Plenary on Close Reading. Advanced Narrative Medicine Workshop - Program in Narrative Medicine. College of Physicians & Surgeons of Columbia University, June 23, 2008.

3. Monroe A, Ferri F, Borkan J, Dube C, Taylor J, Frazzano A, Macko M. Doctoring. Providence, RI: Warren Alpert Medical School of Brown University, 2005-10.

4. Wald HS, Davis SW, Reis SP, Monroe AD, Borkan, JM. Reflecting on Reflections: Medical Education Curriculum Enhancement with Structured Field Notes and Guided Feedback. Acad Med, 2009; 84(7): 830-7.

5. DasGupta, S. Narrative Humility. Lancet, 2008; 371: 980-1.

6. Kerka, S. Journal writing and adult learning. ERIC Dig., 1996; 174:1-4.

7. Wald HS, Reis SP. A Piece of My Mind. Brew. JAMA, 2008; 299:2255-6.

8. Jacobus, L. http://literatureartandideas.blogspot.com/ [Accessed February 16, 2010].

9. Wald, HS. I've Got Mail. Fam Med, 2008; 40(6): 393-4.

10. Reis SP, Wald HS, Monroe AD, Borkan JM. Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative): A framework for enhancing educational impact of faculty feedback to students' reflective writing. Patient Educ Counseling, 2010; doi:10.1016/j.pec.2009.11.014.

11. Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional Formation: Extending Medicine's Lineage of Service Into the Next Century. Acad Med, 2010; 85(2): 310-7.

12. Horowitz CR, Suchman AL, Branch WT, Frankel RM. What Do Doctors Find Meaningful about Their Work? Ann Intern Med, 2003; 138(9): 772-5.


Fostering Interdisciplinary Community: A Humanities Perspective

February 18, 2010 at 6:42 pm

Commentary by Jessica Howell, Ph.D., Wellcome Postdoctoral Research Fellow, Centre for the Humanities and Health, King's College London

Described as a "free destination for the incurably curious", the Wellcome Collection in London consists of several galleries, a cafe, bookstore and library. The library houses "collections of books, manuscripts, archives, films and pictures on the history of medicine from the earliest times to the present day". I knew that this particular library's holdings would be an invaluable resource for my research in the medical humanities, so I decided to pay the Collection building a visit, soon after I arrived in London this January. I was doubly interested because the Wellcome Trust, established by Sir Henry Wellcome's will in 1936 and meant "to advance medical research and understanding of its history", funded the Centre for the Humanities and Health at King's College London, where I hold my current position as postdoctoral research fellow.

I enjoyed the Wellcome Image Award gallery, which displays winning medical and historical images made by light and electron microscopy as well as illustration and photography. But I was perhaps most forcibly struck by "Medicine Man: The forgotten museum of Henry Wellcome", which exhibits objects from Wellcome’s personal collection. Sir Henry was apparently a dedicated gatherer of medical and anthropological artifacts and curiosities. Amongst the assortment are forceps, chastity belts, ceremonial masks, early surgical instruments such as bone saws, and even torture chairs. I found myself thinking of the exhibit for a long time afterwards. Imagine the research that could be done, and no doubt already has begun, on each of these object’s long, fraught histories, and what such research tells us about a culture's values, practices, even aesthetics. Because I found certain objects disturbing, I also felt responsible to pay even closer attention to what they had to teach me-about medicine's relationship with gender and race, as well as about common human experiences of birth, death, pain, suffering, and healing. I wished I had a medical doctor, artist and social scientist, amongst others, standing in the room, contemplating with me this window into complex and often troubling moments of human history.

Though I was alone at the Wellcome Collection itself, I am in the fortunate position of being able to participate in just such meaningful discussions in my role as Wellcome Research Fellow. I am part of a multi-strand program called the "Boundaries of Illness", convened in the Centre for Humanities and Health here at King's College. I work within a strand of this program titled "Nursing and Identity: Crossing Borders". For my project, I will examine the lifewriting of nurses traveling in the late nineteenth and early twentieth centuries under the auspices of the Colonial Nursing Association. I will analyze their work in terms of its implications for medical history, literary, postcolonial, gender and travel studies, and help to write a database for future researchers. To the research team at King's College, I bring a background in literary studies. I received my Ph.D. in English literature from University of California, Davis in 2007. My own work has been concerned with racial science and climate in nineteenth-century travel narratives. I applied to the research fellowship at King's partly due to my own long-standing interest in interdisciplinary scholarship and colleagueship. For example, while at UC Davis, I co-organized a medical humanities research group with Faith Fitzgerald (Internist and Professor of Medicine and Associate Dean of Humanities and Bioethics), and we also hosted two conferences on "Literature and Pathology."

Through these experiences, I have found that being part of an interdisciplinary scholarly community can enhance my own work in both tangible and intangible ways: on a pragmatic level, I produce better honed research when I analyze my arguments from alternate perspectives, testing the validity of my assertions outside of my own discipline. I may follow up leads provided by my colleagues that will take my work in new and creative directions. I also use research methodologies drawn from various academic traditions. Less measurable, but still critical to my work, are the interpersonal benefits: I find myself energized and encouraged when surrounded by scholars who have chosen this kind of study-speaking generally, I find that they tend to be more willing to explicitly discuss the ethical implications of their research, or even the underlying ideals and values they hold, such as human connection, compassion and understanding. Specifically, many of us in the interdisciplinary field of medical humanities believe that it is only through a meeting of the minds between biomedicine and other fields such as literature, art, philosophy and history that we can understand the experiences of patients and providers of care (roles that almost all of us will inhabit at some point in our lives). The Centre's website says it well: "Patient subjectivity and values - sometimes bundled together as 'the patient voice' - are expressed in a wide diversity of cultural objects and settings (texts, symbolic figurings rendered in portraits, films and in conceptual constructions), which it is the task of the Medical Humanities to identify, research and illuminate" (http://www.kcl.ac.uk/research/groups/chh/about.html).

As I have stated that I value my colleagues' diverse perspectives and the collaborative quality of interdisciplinary research, it would be remiss of me not to include the experiences of some of my King's coworkers. Dr. Rosemary Wall began her post in 2007, and so has seen the Centre develop through the stages of proposal, planning, and now implementation. She mentioned that it has been rewarding to help bring together scholars from within King's College and from other institutions who have common interests and complementary training, but may not have known each other or had the opportunity to share their ideas before (personal interview 2/4/2010). Ms. Elisabetta Babini asserts that, while "commitment to Medical Humanities" is "highly challenging", the field also has great potential to "broaden traditional research horizons." Both of my colleagues discussed the rich professional opportunities provided by their work in the Centre. As just one example, they are currently co-planning Screening the Nurse: Call to Service, a two-day event of talks and film screenings organized around the theme "British Nurses and Wars", hosted by the Florence Nightingale School of Nursing and Midwifery at King’s College in collaboration with the Imperial War Museum film archive (e-mail interview, 2/7/2010). These kinds of projects offer researchers in the medical humanities unique venues and opportunities through which to broaden their professional network and gain valuable cross-disciplinary experience, as well as to make their research accessible to the public. I am very pleased to have joined with the Centre in supporting its initiatives. Further, I look forward to sharing in the future some of my findings regarding nurses' writing, which I agree, with recent commentators Cortney Davis and Thomas Long, is a topic of ongoing interest.

References:
1 For more on Sir Henry's personal collection, see An Infinity of Things: How Sir Henry Wellcome Collected the World by Frances Larson. (Oxford: Oxford Univ. Press, 10 Sep 2009)

2 Within the "Nursing and Identity" strand of this project, I am supervised by Professor Anne Marie Rafferty, Dean of the School of Nursing and Midwifery, and Dr. Anna Snaith, Reader in Twentieth-Century Literature. My co-researchers include Dr. Rosemary Wall, postdoctoral medical historian, and Elisabetta Babini, Ph.D. student in Film Studies/ Nursing, who both kindly agreed for me to include their comments.

Disease Causality

October 12, 2009 at 9:55 am

Obese man eating fatty and sugary foods. Photograph, Anthea Sieveking, Wellcome Images

Commentary by Daniel Goldberg, J.D., Ph.D. Health Policy & Ethics Fellow, Chronic Disease Prevention & Control Research Center, Department of Medicine, Baylor College of Medicine; Research Faculty, Initiative on Neuroscience & Law, Department of Neuroscience, Baylor College of Medicine

There is a legal doctrine known as "attractive nuisance." The basic idea of the concept, grounded in the law of torts, is that an owner or occupier of a premises can be held liable for negligence if they are responsible for a dangerous condition which is reasonably likely to attract vulnerable persons, such as children. Sometimes the medical humanities are for me akin to an attractive nuisance inasmuch as I tend to be easily distractible and scatter-brained, and thus can wallow in to deep pools before I realize I am well out of my "safe" zone.

Of course, practicing the medical humanities is not a nuisance at all; it is a privilege to be practicing, instead of merely rhapsodizing about the merits of, an interdisciplinary approach to health, illness, and medicine in society. But the privilege comes with significant danger as well, and I have of late become more impressed with the need to focus in on a few key areas which I hope to make part of my comfort zone. One of these areas of interest is disease causality.

Causation

Causation is one of those fecund topics whose enormous importance seems to surpass disciplines. A favored subject of antiquity, it remained central to Thomas Aquinas, Maimonides, and many of the other medieval scholars, to the early modern greats like David Hume and Immanuel Kant, and remains a critical subject in contemporary philosophy of science. Kant, whose epistemology is in my view often shamefully relegated to the background of his moral philosophy, was convinced that causation is a category of understanding, such that we cannot make sense of the phenomenal world without the concept.

But not only philosophers treat of the importance of causation, especially in context of medicine and illness. Medical anthropologists, for example, have long since pointed out that comprehending how a given community understands disease causality provides critical insight into the meaning of illness, suffering, life, and death. Anne Fadiman's well-used book, The Spirit Catches You and You Fall Down [1], is a nice instrument for teaching this point, as it seems inescapable that greater understanding (if not acceptance) of the Lee family's beliefs about Lia's illness experience would have greatly improved the family's medical experience.

As a self-identifying public health ethicist, my particular focus right now in thinking about disease causality is in the context of stigma. The history of stigma in context of illness can, to my mind, be traced back virtually as far as one wishes in Western civilization. (I believe it is reasonably prevalent in non-Western cultures as well, though I admit to a shameful level of ignorance on the specifics here). The reasons why stigma is so common in illness scenarios are multi-faceted, complex, and in my view have powerful explanatory capacity in conceptualizing health, illness, and disability. Fortunately for the able readers, as I have some work in review on the subject, I shall not be discussing it here (though some general thoughts on the subject are available on Medical Humanities Blog.

Disease Causality and Stigma: The Case of Fatness

What I want to suggest here are the connections between a particular notion of disease causality and stigma. One of the most obvious examples is the relationship between fatness and illness. As Gard and Wright [2] painstakingly documented in their fabulous 2005 book, the connections between fatness and disease are typically taken to be virtually certain among both lay and professional communities. And what are the consequences? That is, what results if we assert that type II diabetes, coronary artery disease, and cardiovascular disease, among others, are caused by fatness?

Of course, responding to the question of "what causes diabetes" by answering "fatness" is really a set of additional questions masquerading as an answer. Many of these questions turn on the differences between causes and risk factors, but to approach the issue of stigma, one must ask what causes fatness? (Naturally, to even speak of singular causes of intricate, nonlinear systems like disease in populations is absurdly oversimplified; one of the problems with causal attributions of illness in both lay and professional discourse is our general reduction of these complex systems to single, discrete variables. This is of course a hallmark of the Western scientific method, and the history of how we came to do so is, I think, quite important. But that is another post altogether.)

Life-style Model of Disease

In any case, what causes fatness? The usual answer turns on some fairly innocuous-sounding mishmash of genetics and environment, but the so-called model of disease causality here is often referred to as the "lifestyle" model. And lifestyle-type thinking is, particularly in American culture, deeply ingrained with notions of choice. We choose whether to pursue this lifestyle or that one; and so, in a very real sense, we choose whether to be fat. If fatness causes illness, it follows that we choose whether to be sick (with diabetes, coronary artery disease, etc.). This is in part why breathless reports of genetic linkages with fatness incite so much controversy - one of the perceived implications of such linkages is that individuals are not responsible for their fatness.

Of course, as I have noted on Medical Humanities Blog (see "On the Genetics of Jewishness"" and "On Genes & Diabetes Disparities", our discourses of genetic causation are problematic in a great number of ways, not least of which is the notion that "genes" actually cause anything at all in a linear sense. Genes do have causal effects, of course, but those causal effects are only produced through a complex system in which social, economic, cultural, and environmental factors profoundly shape expression. As Jeremy Freese has noted, the idea that the causality of an illness can be divvied up into x% - genes and 1-x% - environment is deeply mistaken [3]. Thus mere genetic linkages themselves are, from a causal perspective, not very interesting separate and apart from the inordinately complex systems through which they express (or do not).

Critique

One of the most compelling criticisms of the lifestyle model of disease is not that it is false; but rather, it is incomplete inasmuch as it pays no attention to the ways in which social and economic conditions substantially determine one's lifestyle choices. Even if we were to grant the exceedingly dubious proposition that fatness causes diabetes, drilling the causation down to individual lifestyle choices ignores, in my and many others' views, the robust evidence that lifestyles are primarily the product of social and economic conditions (the social determinants of health).

And of course, our model of disease causality is frequently embodied in how we regulate behaviors thought to cause illness. If one sees society as what Robert Jay Lifton termed a "biocracy" [4] as prevailed in the early 20th century in both Europe and the U.S., then the solution to the inherited "degenerate" behavior that produced diseases like insanity, mental retardation, and syphilis was to enact laws which precluded such inheritance. Alternatively, one could also support laws that precluded the "amalgamation" of "racial stocks" in which such degeneracy proliferated.

Similarly, if the cause of diabetes and CAD is perceived to be fatness, and the causes of fatness are unhealthy lifestyles, the perceived public health solution is to regulate such lifestyles, by, for example, strictly regulating the food available in school cafeterias, or requiring restaurants to print calorie information on their menus and web sites. In contrast, if the cause of fatness is perceived to be social and economic conditions, policy solutions would seem to fall much closer to ameliorating the conditions which seem to promote unhealthy lifestyles. (I hasten to remind readers that I am quite skeptical of the causal links between fatness and illness, but I assumed the validity of the attribution to take the point further).

In any case, disease causality is an important, and, in my view, understudied concept in the medical humanities, one that ties in quite deeply to notions of stigma, disability, and moral culpability for illness.

References
1. Anne Fadiman. The Spirit Catches You and You Fall Down (New York: Farrar, Straus & Giroux, 1997).
2. Michael Gard and Jan Wright. The Obesity Epidemic: Science, Morality, and Ideology (New York: Routledge, 2005).
3. Jeremy Freese. "The Analysis of Variance and the Social Complexities of Genetic Causation," International Journal of Epidemiology 35, no. 3 (2004): 534-36.
4. Robert Jay Lifton. The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 2000).

 

Locating Narrative In Medicine’s Moral Domain: Notes (Musical And Otherwise) From A Recent Presentation

June 15, 2009 at 4:19 pm

A Group of Musicians

Commentary by Martin Kohn, Cofounder and Senior Associate for Program Development, Center for Literature, Medicine and Biomedical Humanities at Hiram College, and retired faculty, Northeastern Ohio Universities College of Medicine

My wife is a nephrologist. She loves kidneys (and how they function) almost as much as she loves me. We recently celebrated our 23rd anniversary. She's a deductive thinker par excellence. I'm a lateral thinker to the nth degree. When we argue she'll often exclaim, "I can't follow your train of thought." "What train?" I reply earnestly. Recently, she asked me (again), "can you define narrative for me?" "Not yet," I replied, buying a little more time.

In spite of working in the medical humanities for nearly 30 years I continue to struggle with explaining just what narrative is and how it permeates medicine's moral domain. So I recently agreed to a request to present grand rounds to the Bioethics Department at the Cleveland Clinic, forcing myself to ransack old notes and articles and catch up with at least a few developments in the field. I offer below a sampling of my presentation. The through line was:

WORDS/STORIES——————-PERSONS———————-COMMUNITY

WORDS/STORIES

I began this portion of the presentation with numerous claims about the centrality of words and stories in our lives: that they are as constitutive of the self as are our genes; that they preserve "the teller from oblivion." (1); that they are the foot soldiers of meaning; that they "do not simply describe the self, they are the self's medium of being. " (2); that narrative is a conveyance in which and through which we (and our words and stories) confront time, and that ultimately, meaning and sense filled words and stories, into which we are born and which are temporally borne by us, become our constructed truths about the world (noting that the root of the word narrative, "narr/gno," is after all, knowledge.).

Finally, I claimed that words and stories also make community possible. Community being formed by which bits of experience we choose to string together (to re-member, both individually and communally) and which we re-present as plotted events, connecting us to the unfolding drama of our shared lived experience.

Further exploration of the centrality of story in the work of physician-writers Robert Coles, Rachel Naomi Remen and Rita Charon was followed by a synopsis of creative writer, Scott Russell Sanders' essay, "The Power of Stories" (3).

PERSONS

After a brief exploration of Cassell's notion of "topology of person," (4), I focused on a more poetic treatment of the aspects of the person that appears in a poem by Billy Collins, "The Night House." The poem reveals the body's role-as "the house of voices"- in the experience of the person who lives in the moral lifeworld as that body, and who "Sometimes puts down its metal tongs, its needle, or its pen/To stare into the distance,/To listen to all its names being called/Before bending again to its labor" (5).

These voices (heart, mind, soul, conscience) in the body's house are arrayed below (with attributes I provisionally assigned them) where they serve as elements of the first of three tributaries flowing into moral personhood.

First tributary: THE HOUSE OF VOICES /IN THE EMBODIED PERSON/ IN THE MORAL LIFEWORLD

•The open (feeling) "heart"
•The curious (improvisational) "mind"
•The seeking (animating) "soul"
•The silvery (calculating) "conscience"

Second tributary: EXPRESSIONS OF MORAL REFLEXIVENESS/OUR MORAL BEING IN THE WORLD

I shared with my audience a most delicious description of "character" which is, I believe, the primary vehicle through which moral reflexivity operates. The excerpt below comes from the novel, Mrs. Ted Bliss, by Stanley Elkin:

the constant, minute-to-minute routine of putting together a character, assembling out of little notes and pieces of the past-significant betrayals, deaths, yearnings, successes, meaningful disappointments, and sudden gushers of grace and bounty- some strange, fearful archaeology of the present, the Self to Now, as it were, like a synopsis, some queer, running quiddity of you-ness like a flavor bonded into the bones, skin, and flesh of an animal.

Third tributary: REFLECTIVE PRACTICE/DOING MEDICAL ETHICS OR BIOETHICS THROUGH PARTICULAR FRAMEWORKS

A (partial) list of the reflective frameworks appears below:

•Juridical: Study of the rational application of principles as action guides. Morality is seen as a body of knowledge. (7)
•Narrative: Study of voice and authority, point of view, coherence of story, co-construction of story, narrative frameworks of illness stories, etc. Morality is seen as a continual interpersonal task done by all in the community. (7)
•Care: Study of what empathy calls forth from us
•Feminist: Study of systemic/historic power imbalances and calls to challenge those imbalances
•Communicative: Study of the distortion of free communication /attempts to remediate those imbalances
• Naturalized: "Minimally, naturalism in ethics is committed to understanding moral judgment and moral agency in terms of natural facts about ourselves and our world." (8).

Combining these tributaries into EMBODIED BEING AND DOING produces movement, a kind of flowing moral lifestream that conveys a style or action that contains a certain musicality to it. So I searched for two musical examples to visually and aurally illustrate what I meant by musicality. The first example is a rendition of Johnny One Note (The ads will disappear after about 30 seconds, if you try to remove them the video starts over). The second example features the song Libertango by Astor Piazzolla (originator of the Nuevo Tango style, who plays the bandoneon, a folk instrument related to the accordion, with an ensemble including Yo-Yo Ma).

Johnny One Note is a show tune from the 1937 Rodgers and Hart musical Babes in Arms. Title, lyrics and in this instance, performing style, all align (for me) as a critique of the hegemonic "principlist" approach to moral analysis of medical issues. Featured in this rendition of Johnny One Note is Johnny Mathis (as an alpha male!) surrounded by the adoring Lennon Sisters, backing him to the hilt as he gives his all for ONE NOTE (autonomy?). In contradistinction, Libertango is polyrhythmic, featuring layered and shifting voices and is multi-genre, a mix of classical and jazz and folk music. It represents well the "multiple tributaries" approach that revels in the complexity (and beauty) of the moral lifeworld that I advocate.

COMMUNITY

To finish my presentation, I turned to two works, "The Narrative Quality of Experience, by Stephen Crites (9); and Gerald Gruman's A History of Ideas about the Prolongation of Life (10). Stephen Crites was a philosopher and a scholar of religion with special interests in the connection between narrative and experience. His work emanates from and illuminates the point at which experience and action interpenetrate, where narrative becomes the vehicle through which consciousness temporally expresses experience; and where simultaneously our actions take on a particular musicality in response to the expressed stories we live our experience out of. (How do we label the iconoclast/the oddball, one who doesn't live by the conventional expectations or stories of our culture? We do so by saying that they "march to the beat of a different drummer.")

Most pertinent to the focus on community are Crites' contentions about sacred and mundane stories. He explains: "people live in [sacred stories which] are anonymous and communal… [that] orient the life of people through time, their life-time, their individual and corporate experience and their sense of style, to the great powers that establish the reality of their world…[ this makes, he claims] every sacred story a creation story…the story itself creat[ing] a world of consciousness and the self that is oriented to it" (pp. 295-6). He further explains that these sacred stories are always present in some way in the mundane stories [and that] "people are able to feel this resonance; because the unutterable stories are those they know best of all" (pp.296-7). He believes that "the stories people hear and tell, the dramas they see performed, not to speak of the sacred stories that are absorbed without being directly heard or seen, shape in the most profound way the inner story of experience"(p. 304).

Crites anticipated (he was writing during the late 1960's) a conversion of consciousness that reflected a cultural shift into post-modernity. Evidence for the shift would be found, he explained, in "a traumatic change in man's story" (p. 307), wherein the stories to which he has "awakened to consciousness must be undermined… [and] through a new story both the drama of his experience and his style of action must be reoriented… he must dance to a new rhythm… [for] the very cosmos in which he lives is strung in a new way" (p. 307).

I took Crites' notion of sacred stories and shift of consciousness and set them within the work of another philosopher, Gerald Gruman- challenging us to consider that the shift in consciousness that Crites was sensing about 40 years ago, has now reached a critical point.

In his classic work, A History of Ideas about the Prolongation of Life (published five years prior to Crites' article), Gruman provides ample evidence of the human yearning for immortality, citing numerous examples across time and cultures; however, he also describes an alternative historical-cultural phenomenon: acceptance of our body's limitations. He presents his evidence of these two urges through two conceptual domains: the Meliorist camp, i.e. the 'we can continuously improve the human condition' folks, and the Apologist camp, i.e. the 'we need to accept ourselves the way we are' people.

These camps, and both of these human urges, are in tension- and I would argue are competing sacred stories about immortality. The meliorist camp promotes solipsistic immortality; the apologist camp supports species immortality. H. R. Moody, philosopher and humanistic gerontologist, has offered two similar framing concepts: one, aligned with a sacred story of progress and human control over nature, he labels 'techno-utopian mastery'. (11) Aligned with the sacred story from the apologist standpoint of mystery or acceptance of our place in the natural order of the world is his 'ecological vision of aging'a"where youth and age are…. accepted as part of the natural life cycle" (p. 33).

AIA offered to my audience a neologism to describe a synthesis of the two sacred stories -the one grounded in mystery and reverence, the other grounded in mastery and control. The word I coined is eco-meliorism. It grew out of a new sacred story, the one to which I believe our consciousness is awakening- sustainability- and which I define as the careful (even slow) movement toward human betterment in light of human presence in ongoing, interrelated natural systems.

Sustainable Health

There is evidence that we in medicine (and our larger community) are beginning to live within the sacred story of sustainability, developing interesting syntheses that emanate from an eco-meliorist approach. I would include in this list hospice and palliative care, the Eden Alternative in nursing homes, and the Planetree organization. There's also movement toward the sustainability story in science- Bioneers (whose motto is "revolution from the heart of nature") , green chemistry, and the adoption by some of the "precautionary principle." In our larger society there are other examples of eco-meliorism including the slow food movement and even a call for slow money, such as that advocated by Woody Tasch. (See his book, Inquiries into the Nature of Slow Money. Investing as if Food, Farms, and Fertility Mattered).A All of these endeavors point toward a new sacred story of sustainability, toward stringing our cosmos in a new way, toward waking up into a new consciousness, toward marching to the beat of a different drummer.

Wallace Stevens wrote the poem "Six Significant Landscapes" nearly 100 years ago (12). I ended my presentation (and now this blog entry) with its final verse and with a question: How might we live and practice and think differently if we lived in different "rooms", if we changed not only our physical habitat, but also our narrative habitat? (And now, I think I'll grab a glass of wine, put on my sombrero, and read the poem to my wife….)

Rationalists, wearing square hats, / Think, in square rooms, / Looking at the floor, / Looking at the ceiling. / They confine themselves / To right-angled triangles. / If they tried rhomboids, / Cones, waving lines, ellipses — / As, for example, the ellipse of the half-moon — / Rationalists would wear sombreros.

References

1. Portelli, Alessandro. The Death of Luigi Trastulli, and Other Stories: Form and Meaning in Oral History. (Albany, N.Y. : State University of New York Press) 1991, p. 59

2. Frank, Arthur W. The Wounded Storyteller: Body, Illness, and Ethics. (Chicago: University of Chicago Press) 1995, p. 53

3. Sanders, Scott Russell. The power of stories. Georgia Review, 1997; 51:113-26.

4.Cassell, Eric J. The Nature of Suffering and the Goals of Medicine. (New York: Oxford University Press) 1991, p. 47

5. Collins, Billy. Picnic, Lightning. (Pittsburgh, Pa.: University of Pittsburgh Press) 1998, p.80

6. Elkin, Stanley. Mrs. Ted Bliss. (New York: Hyperion) 1995, p. 55

7. Lindemann Nelson, Hilde. Context: backward, sideways, and forward. In Charon, R., Montello, M., eds. Stories Matter: The Role of Narrative in Medical Ethics. (New York: Routledge) 2002

8. Walker, Margaret Urban. Introduction: Groningen naturalism in bioethics. In Lindemann, H., Verkerk, M., Walker, M.U., eds. Naturalized Bioethics: Toward Responsible Knowing and Practice. (Cambridge and New York: Cambridge University Press) 2009, p. 1

9. Crites, Stephen. The narrative quality of experience.A Journal of the American Academy of Religion, 1971: 39:291-311

10. Gruman, Gerald J. A History of Ideas about the Prolongation of Life: The Evolution of Prolongevity Hypotheses to 1800. (Philadelphia: American Philosophical Society) 1966

11. Moody, H.R. Who's afraid of life extension? Generations, 2001-02; xxv: 33-37

12. Stevens, Wallace. Harmonium (New York: A. A. Knopf), 1993, p. 100

Walking The Dog: Incorporating Poetry To Help Learners Connect With Relationship-Centered Care

April 30, 2009 at 10:06 am

Satirical scene with doctor diagnosing well to-do man with Diabetes
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

Theories of relationship-centered care

The concept of relationship-centered care (RCC) (1) and the related theory of human interaction designated Complex Responsive Processes of Relating (2) remain exceptionally fruitful ways of thinking about doctors and patients. Relationship-centered care includes attention to the personhood of both doctor and patient, as well as their respective roles; awareness of the importance of emotions in both the patient and the doctor; and recognition of the reciprocity of influences from both doctor and patient (and from the wider healthcare system and society itself) on the relationship itself (1,3,4). RCC challenges the notion of compassionate detachment and instead explores connection and engagement with patients as the most appropriate and moral foundation for relationship.

The theory of Complex Responsive Processes of Relating (2) highlights the nonlinear, reciprocal, and self-organizing nature of human interaction. It specifies that patterns of meaning and relating are co-created continuously throughout the communicative encounter; and that such patterns may repeat themselves, or due to the introduction of "novelty," may develop spontaneously in new directions. As Suchman writes, "the development of new patterns depends upon the diversity and the responsiveness in the interaction." (p. S42). In other words, encounters between doctors and patients that allow, even invite, variety and divergence from unprofitable patterns are most likely to evolve into more meaningful and more authentic ways of being in relationship, which ultimately serves patient well-being. This view acknowledges that patients as well as physicians exercise continually shifting power in the encounter; and therefore physicians have limited control in terms of outcomes.

Implications of RCC/CRPR for "noncompliance"

Although RCC and CRPR have implications for all aspects of the patient-doctor encounter, they are especially relevant in situations of perceived patient "noncompliance." Advances in social science research have helped challenge simplistic conceptualizations of adherence and compliance, in which doctor-patient communication consists of the doctor prescribing medication and the patient taking it. More recently scholars have introduced the term "concordance" to indicate the complex processes that must occur between physicians and patients in order to result in patient cooperation with the prescribed treatment regimen (5). For example, concordance implies an open exchange of ideas, rather than top-down orders, and focuses on both physician and patient values and priorities, rather than on those of the patient alone.

Nevertheless, walking the corridors of a contemporary hospital of clinic, one rarely hears reference to "lack of concordance." Chart notes still read, "Patient noncompliant with medication," with all the frustration and patient blame this term has come to imply (6). Neither do we often hear clinicians contemplating the implications of their diabetic patients' - or their own - emotional responses to their disease for the meaningfulness of future patient encounters; nor the applications of complexity theory to patient compliance. On these significant dimensions of interaction around diabetes care, as in so many other aspects of medical education, the gap between the formal and the hidden curriculum remains pronounced (7). In my comments below I will focus specifically on current attitudes of physicians and students toward the management of diabetic patients; and how the use of a poem can help learners clarify principles of RCC and CRPR that are pertinent to adherence/compliance dilemmas.

The frustrating case of diabetes

In the diabetic patient population, noncompliance is a widespread (and ill-defined) problem, with estimated rates ranging from 30-80%. The inability to "control" the patient, and therefore "control" the patient's blood sugar, is a source of substantial exasperation, even despair, among physicians. Yet one study (6) found that, despite physicians' awareness of the complex constellation of psychological and social factors that constitute obstacles to treatment, they routinely failed to address these issues in clinical encounters, relying on directive, one-way communications about numerical monitoring and outcomes. In other words, these physicians persisted in a linear, cause-and-effect, power-down communication model that ignored the complexity, emotionality (in themselves or their patients), spontaneity, and power fluctuations that occur continuously between doctor and patient. In another study of physician attitudes toward poor compliance in patients with diabetes, it appeared that doctors relied primarily on shock, pressure, and the threat of hospitalization to influence patients toward improved compliance, as defined by the physician (8).

Medical students as well can cling to the straightforward, linear models of communication that are often mistaken for patient education in the management of diabetes. Their focus (understandably, from their perspective as learners), is on diagnosis of the physical ailment. Once this is achieved, the rest seems easy to them: the doctor tells the patient what to do; and the patient, who naturally wants to recover, does it (9). One study noted that, in actual encounters with patients with diabetes, the most frequently reported challenge to student worldviews was how to achieve patient compliance (10). It does not require a great leap to expect that these students will likely become patronizing, directive, yet also despondent and frustrated physicians.

Poetry to the rescue?

While it is obviously crucial to help students rethink their assumptions about and gain insight into the relational foundation of medicine and the complex nature of communication, especially around the issue of compliance, the methods for doing so remain unsettled. By definition, RCC and CRPR are intricate, multifaceted constructs at variance with more simplistic mechanistic models of doctor-patient interaction, and this suggests that the ways of developing conversations addressing them must be versatile as well. Under these conditions, literature and poetry may well have a role to play in helping students develop more critical, self-aware thinking about relationship in general, and in particular about the process through which patients and physicians achieve concordance regarding drug and lifestyle regimens. To illustrate this point, I would like to consider John Wright's wonderful poem "Walking the Dog," (11) and how it clarifies and concretizes aspects of both RCC and CRPR, as well as complexifies students' thinking about patient compliance.

Walking the dog

In "Walking the Dog," a doctor looks at an old problem - an overweight patient with diabetes - in a new way. The doctor is frustrated - obesity and high blood sugars are killing his patient. He turns the problem over and over in his mind. What can he do? At last he has an epiphany - he will give his patient a little dog that she can walk, thereby providing her with much-needed exercise, that will in turn lower her weight and her sugars, and prolong her life. And, like the conscientious physician he is, he prescribes the puppy in a precise dosage: the animal must be walked twice a day!

At this point in the poem, the author (himself a physician) has already caught our attention. Prescribing a pet! This unusual approach helps students think outside the box in terms of innovative therapies. It also is an excellent illustration of the CRPR principle that patterns of meaning and relating are continuously created, and that while they may exhibit stability, sometimes new patterns arise spontaneously (novelty). At this point the students think they "get the message": treatment can involve something more than medication. Be bold, be daring! They can "tell" their patients to take a walk! They admire the physician for being so creative. But the author provides an additional twist (yet more novelty). To their chagrin, the students discover that the treatment doesn't work, at least not in the way the doctor thought it would. As it turns out, while the patient is delighted with her little puppy and cuddles it affectionately, it is her "lean" husband who "faithfully" complies with the prescription of twice-a-day dog walking. Twelve years later, happy but presumably still obese and still diabetic, the patient dies.

The narrative arc of the poem is so unexpected that it inevitably provokes a chuckle. Nonetheless, it is troubling to students on several counts. First it turns the concept of compliance on its head by showing that, in the poem, the compliance achieved is perfect but meaningless because the wrong person is doing it. This nonsensical take suggests that compliance is only one aspect of the encounter between patient and doctor and should not always be regarded as the only measure of success. Both the narrator (and we, the readers) have to grapple with the fact that patients don't always do what doctors tell them to do. In CRPR terms, students learn that doctors do not have omnipotent control over their patients. In discussing why the patient may have been unable to or uninterested in walking her puppy, students realize that following "what the doctor says" is influenced by many factors; and that while the physician's power may be rooted in expertise, in this case the patient has her own power, and exercises it by choosing a relationship with the puppy that is very different than the one the doctor envisioned, but one that nevertheless brings her joy.

In one final twist, the poem's artistry offers an additional puzzle. Somehow, despite the physician's initial frustration, despite the failed prescription, despite the ultimate demise of the patient, this is a gentle, bemused, and humble poem that effectively conveys the value of the doctor's caring and concern for his patient. From an RCC perspective, the poem shows us a doctor, patient, (and spouse) who are not simply roles, but people with emotions, idiosyncracies, frustrations, and affections. The narrator, for example, is well aware of both his own emotions, and those of his patient, and he is not afraid to introduce novelty to attempt to create new patterns in the situation.

Perhaps one of the most important lines occurs early in the poem, when the doctor realizes that his patient's health is deteriorating and that, so far, he hasn't been able to save her. At this point the narrator says, "So/I thought." This line illustrates the self and situational awareness that CRPR and RCC both advocate. By reflecting on his own and his patient's limitations, and the exasperation he feels at these constraints, the physician is able to develop empathy. Unwilling to give up or emotionally abandon his patient, he also resists giving in to his own annoyance and helplessness. Instead he keeps trying. In CRPR terms, the physician approaches his patient's "noncompliance" with curiosity, compassion, and more than a modicum of humor, rather than fear and defensiveness. Rather than burden himself with self-blame and guilt (the consequences of unrealistic control aspirations), he simply remains open to the possibility of change. And apparently he remains open for twelve years. Did he achieve better A1C numbers in his patient? Did he extend the patient's life? The poem is silent on these questions. But most students feel that doctor and patient shared a precious partnership, and that the physician's position in relation to the patient was fundamentally a moral one.

Conclusion

Prose and poetry have an important contribution to make in helping medical students engage with the abstractions of conceptual theories such as RCC and CRPR even as they wrestle with the challenges of issues such as adherence/compliance. Of course, the relational and communicative questions raised by RCC and CRPR play out daily between doctors, medical students, and patients, and obviously such encounters provide fertile soil for examination. Physician educators (12) have crucially advocated, and rightly so, for real-time, moment-by-moment awareness of actual clinical process. But just as Dr. Wright found value in retrospective reflection about himself and his patient, so too can students benefit from teaching experiences in which the priority is stimulating critical awareness, as well as the multi-tasking reflection that is required at the bedside. Through humanities teaching such as I have described above, the ways of perceiving and being that RCC and CRPR encourage become increasingly accessible and meaningful to students, and help create and sustain "attitudes of readiness" that, in turn, will seamlessly interface with and support their "real" lives as burgeoning physicians.

References
1. Beach MC, Inui T, and the Relationship-Centered Care Research Network. Relationship-centered care: a constructive reframing. Journal of General Internal Medicine, 2006;21:S3-8.

2. Suchman AL. A new theoretical foundation for relationship-centered care: complex responsive processes of relating. Journal of General Internal Medicine, 2006;21:S40-45.

3. Frankel RM, Inui TS. Re-forming relationships in health care. Journal of General Internal Medicine, 2006;21:S1-2.

4. Duffy FD. Complexity and healing relationships. Journal of General Internal Medicine, 2006;21:S45-46.

5. Chatterjee JS. From compliance to concordance in diabetes. Journal of Medical Ethics, 2006;32:507-510.

6. Wens J, Vermeire E, Van Royen P, Sabbe B, Denekens J. GP's perspectives of type 2 diabetes patients' adherence to treatment: a qualitative analysis of barriers and solutions. BMC Family Practice, 2005;6:20

7. Hafferty F, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine, 1994;69:861-71.

8. Freeman J, Loewe M. Barriers to communication about diabetes mellitus. Patients' and physicians different views of the disease. Journal of Family Practice, 2000;49:507-12.

9. Anderson RM, Robins LS: How do we know? Reflections on qualitative research in diabetes. Diabetes Care, 1998;21:1387-1388.

10. Mitchell A, Paul TJ, LaGrenade J, McCaw-Binns A, Williams-Green P. Assumptions about disease treatment challenged in a family health clerkship: views of first clinical year medical students. Education Health, 2005;18:14-21.

11. Wright JC. Walking the dog. In Belli A, Coulehan J (eds). Blood & Bone: Poems by Physicians. (Iowa City: University of Iowa Press) 1998, p. 55.

12. Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role modeling humanistic behavior: learning bedside manner from the experts. Acadamic Medicine, 2006;81:661-7..