Commentary by Felice Aull, Ph.D., M.A.; Adjunct Associate Curator, New York University School of Medicine; Editor in Chief, Literature, Arts, and Medicine Database
Now that I’m semi-retired, an elective course that I developed and taught for fourth-year medical students is retiring with me. I'm writing about it here, in the hope that other medical humanities educators might wish to adapt it for their teaching — it was very well received by participating students and, I think, served a useful function. (I believe Linda Raphael has introduced a version at George Washington University School of Medicine). I taught "Betwixt and Between: Borderlands and Medicine," for seven consecutive years at NYU School of Medicine, modifying it somewhat each year. The idea of adapting a borderlands theme to an examination of the medical profession came to me while studying the work of Edward Said and Gloria Anzaldua as I was working toward a master’s degree in humanities and social thought (35 years after getting a Ph.D. in medical science). Below I summarize my motivation for developing the four-week course and elaborate on the syllabus. References annotated in the Literature, Arts, and Medicine Database are linked. Full reading references are listed alphabetically.
Representation, the arbitrary, ambiguity
In his groundbreaking book, Orientalism, Said argues that European discourse constructed a stereotyped Arab identity-the Arab as Other-that was ideologically biased, "regularized," hegemonic, and that enabled the Western imperial project.A Said noted that boundaries are to a great extent arbitrary. Later, Said wrote more generically of stereotyping and subordinating representational practices that must be resisted; he recommended that we should think critically by positioning ourselves "contrapuntally" — from dual perspectives - imagining ourselves as geographic boundary crossers or exiles. Said noted that boundaries are to a great extent arbitrary. It struck me that these themes applied to certain aspects of the institution of medicine and patient-physician interaction, and Bradley Lewis and I co-authored a paper that discussed these analogies (Medical Intellectuals: Resisting Medical Orientalism. Journal of Medical Humanities, Vol. 25, No. 2 / June, 2004, pp. 87-108). We argued that like Orientalism, medical discourse is the cumulative effect of selecting and reconstructing "the patient" and "disease" through the lens of the medical expert. Like Orientalism, medical discourse essentializes and reduces the patient, making empathic communication between physicians and patients difficult. We described how, in contrast to "medical orientalism," several physician writers cross personal and professional boundaries and think contrapuntally in their writing and interaction with patients.
I hoped that a contrapuntal approach to considerations of medical practice and the representation of individuals as "patients" might stimulate medical students to think "outside the box" about the institution of medicine, their future professional roles and interactions. Gloria Anzaldua’s provocative book, Borderlands/La Frontera, provided an additional perspective on borderlands that intrigued me in its applicability to medical education and practice, namely, that borders are often areas of dispute, ambiguity, cultural mixing, and even danger. Students could consider borderland areas of ambiguity in medical practices and training- an exposure that is often missing in their education. Fourth year medical students, being on the border of official designation as doctors, and having a perspective on their medical school experiences, seemed particularly suited to such an approach.
Features of the elective:
- Scheduled as a "full-time" month-long course in February, with no simultaneous clinical rotations or other electives permitted.
- Meets for 2.5 hours each of three mornings per week, for four weeks. Extensive readings, and study of online art and other web materials between sessions fill out the students’ time.
- Two short papers or creative work that responds to the course subject matter
- View and discuss a film on the last day of class
Week 1 topics:
How does the transition from student to professional (professionalization) occur: objectification of the body, responsibility vs. inexperience, instruction in "professionalism" vs. the hidden curriculum
Interaction between professional and personal life
Week 2 topics:
Perspectives on personal-professional and patient-physician boundaries
Narrative and empathy
Week 3 topics:
What is "normal": defining disease; social construction of disability; race and race-based medicine
Difference, rejection, Otherness
Week 4 topics:
Illness as exile
Socioeconomic marginalization and illness
Week 1 : student/professional, personal/professional
Session 1. Introductory session uses poetry and art to introduce topics of cultural ambiguity ("Day of the Refugios" by Alberto Rios, "Original Sin" by Sandra Cisneros), borders between physician and patient ("Talking to the Family" by John Stone, "Open You Up" by Richard Berlin) distancing of the sick from their own health ("Across the Border" by Karen Fiser), isolation (Edvard Munch’s paintings Death in the Sickroom, The Dead Mother).
Arbitrariness of borders, the Other: one-page excerpt from Edward Said’s Orientalism.
Session 2. Objectification of the body as students become acculturated while learning gross anatomy through dissection. Anatomy of Anatomy in Images and Words by photojournalist Meryl Levin traces this process with photographs and student journal entries. Secret knowledge not previously available to the lay public. But now this knowledge is public: Gunther von Hagens’s Body Worlds exhibit.
Student response to gross anatomy course: poem, "Apparition" by Gregg Chesney. Intern trains herself to be detached: poem, "Internship in Seattle" by Emily R. Transue.
Historical perspectives on objectifying and learning from the body:
the dead body — Rembrandt’s painting, The Anatomy Lecture of Dr. Nicolaes Tulp)
the living body-Eakins’s paintings, The Gross Clinic and The Agnew Clinic
development of technology ("Technology and Disease: The Stethoscope and Physical Diagnosis" by Jacalyn Duffin)
Compare representations (paintings) of physician-patient interaction: The Doctor by Sir Luke Fildes and Picasso’s Science and Charity.
Patient’s perspective of objectification and loss of personhood: poem, "The Coliseum" by Jim Ferris
"Professionalism": Jack Coulehan critiques current curricula in medical professionalism and discusses the hidden curriculum. "You Say Self Interest, I Say Altruism."
Difficult transition and ambiguous boundaries when medical student officially becomes an MD. Playing the role, assuming the role. Short story by Mikhail Bulgakov, "The Steel Windpipe"and Perri Klass’s introduction to Baby Doctor and essay from Baby Doctor, "Flip-flops." Klass’s essays include reflections on the interaction of personal and professional life and lead into Session 3.
Session 3. Physician perspectives on the overlap and conflict of personal and professional life; subjectivity, objectivity
Poem, "Falling Through" by Michael Jacobs.
Essay, "Language Barrier". Elspeth Cameron Ritchie.
Essay, "Heart Rhythms". Sandeep Jauhar.
Story, "Laundry". Susan Onthank Mates.
Poem, "Monday". Marc J. Straus.
Poem sequence, "The Distant Moon, I, II,III, IV". Rafael Campo.
Essay, "Fat Lady". Irvin D.Yalom
Week 2: personal/professional and patient/physician
Session 1. Discussion of The Tennis Partner by physician-author Abraham Verghese. A memoir of the author’s personal relationship with a medical student whom he is teaching. It is also a reflection on cultural marginalization and physician vulnerability.
Power relations and physical examination:
Poem, "Physical Exam". David Watts
Essay, "Naked". Atul Gawande
Story, "The Use of Force". William Carlos Williams
Session 2. Narrative and empathy
Rita Charon and Jody Halpern’s theoretical arguments that narrative competence and empathy are necessary skills for proper patient care.
Rita Charon. "The Patient, the Body, and the Self", chapter 5 in Narrative Medicine.
Jodi Halpern. "A Model of Clinical Empathy as Emotional Reasoning" (pp.85-94) and
"Cultivating Empathy in Medical Practice" (129-138) in From Detached Concern to Empathy.
Empathy versus sympathy: poem, "Save the Word". Thom Gunn
Physicians write empathy (crossing boundaries):
Poem, "I’m Gonna Slap Those Doctors". Jack Coulehan
Poem, "Red Polka Dot-Dress". Marc Straus
Essay, "Sleeping with the Fishes". Kate Scannell
Essay, "Learning to Care for Patients, in Truest Sense". Abigail Zuger
Session 3. Patient perspectives on empathy
[first paper due]
Memoir excerpt, "The Patient Examines the Doctor". Anatole Broyard. Broyard’s brilliant commentary argues for emotional engagement, however brief, as beneficial to both doctor and patient — written before the current discourse on narrative and empathy.
Story, "People Like That Are the Only People Here: Cannonical Babbling in Peed Onk." Lorrie Moore. Highlights the divide between medical policies and practices, and suffering patients and their families.
Essay, "Search for wholeness: the adventures of a doctor-patient." Tamara Dale Ball. Dual perspectives from a medical student who has diabetes.
Week 3: health/illness
Session1. Medical uncertainty
From physician perspective: Atull Gawande (essay). "The Case of The Red Leg."
Poem, "Gaudeamus Igitur". John Stone
from patient perspective:"What We Don’t Know" (essay). Gail R. Henningsen.
Poem, "Routine Mammogram". Linda Pastan
Essay, "The Meaning of Normal." Philip Davis and John Bradley.
Article, "Defining Disease in the Genomics Era". L.F.K. Temple, R.S McLeod,S. Gallinger, J.G. Wright
Essay, "What’s Making Us Sick Is an Epidemic of Diagnoses". H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin. New York Times, Science Times, January 2, 2007.
Poem, "Much madness is divinest sense". Emily Dickinson. (No. 435)
Poem, "Monet Refuses the Operation". Lisel Mueller
Problematizing concept of race and race-based medicine
"How Culture and Science Make Race 'Genetic': Motives and Strategies for Discrete Categorization of the Continuous and Heterogeneous" Celeste Condit.
Session 2. Social construction of disability
The Rejected Body: Feminist Philosophical Reflections on Disability. Susan Wendell.
Section from the Introduction: pp. 1-5.
Chapter 2. The Social Construction of Disability.
Poem, "The Magic Wand" by Lynn Manning.
Look at brief video ad online: What if the world had been designed exclusively for people with particular disabilities/impairments?
Turning the Disability Tide: The Importance of Definitions. JAMA, Jan 23, 2008. V.299, NO. 3, pp. 332-334. Lisa Iezzoni, MD and Vicki A. Freedman, Ph.D. (Iezzoni is a disabled MD on Harvard faculty)
"Medical Care Often Inaccessible to Disabled Patients." National Public Radio
"Blocked", by Lisa Iezzoni. Health Affairs, 27/1, 203-209 (Narrative Matters), 2008)
Session 3. Difference, rejection, "Otherness"
Susan Wendell. The Rejected Body, Chapter 3. "Disability as Difference."
Also, pp. 60-69 on Otherness
Optional: Chapter 4. "The Flight from the Rejected Body."
Artists represent physical difference
Alice Neel self-portrait
Sculpture of a pregnant artist who lacks fully formed limbs: Alison Lappert Pregnant (by Marc Quinn)
Artist Laura Ferguson investigates and aestheticizes her own body, deformed by severe scoliosis.
Meaning and discussion of "neurodiversity"
Introduction to Songs of the Guerrilla Nation: My Journey through Autism, memoir by Dawn Prince- Hughes
Week 4: exile, illness, marginalization
Session 1: Exile and illness
Said, Edward W. "Reflections on Exile." Said’s classic essay on characteristics of exile and what can be learned from the exile condition.
Robert Pope. Illness and Healing: Images of Cancer. Artist Robert Pope chronicles the experience of cancer treatment, based on his own treatment for Hodgkin’s disease.
Poem, "Surgical Ward" by W. H. Auden. Inability of those who are well to imagine and identify with those who are ill or injured.
Poem, "Emigration" by Tony Hoagland. Illness as loss of country, a journey with no end in sight.
Online Frida Kahlo art that depicts her dual selves; her loneliness, isolation, stoicism, and resistance:
Self Portrait Between the Borderline of Mexico and the United States
Henry Ford Hospital
The Broken Column
Tree of Hope
Frida and the Miscarriage
Essay, "On Being a Cripple". Nancy Mairs. Incisive well-written essay about language, perception, attitudes surrounding disability-based on her early years with multiple sclerosis.
Essay, "Liv Ullman in Spring". Andre Dubus. Severely and permanently disabled in an automobile accident, Dubus gives a detailed and poetic account of his fears, loneliness, and the human connection provided by an empathetic listener.
Session 2. Marginalization
Story, "From the Journal of a Leper". John Updike. A sculptor who has psoriasis is obsessed with his physical appearance. As his condition responds to treatment, his art and relationships deteriorate.
Essay by Rafael Campo. "It Rhymes with ‘Answer’ ". Campo details how social and cultural marginalization became imprinted on his physical self.
Watch online video showing internalization of racism (3:25 - 5min): "A Girl Like Me."
Memoir by Jimmy Santiago Baca. Prologue, and chapter 8 from A Place to Stand: The Making of a Poet. Baca chronicles his alienation and despair, conditioned by a family history of social and racial marginalization, and how in prison he eventually was able to develop a sense of self-worth through self-education, cultural pride, and writing poetry.
Lee, Don. "About Gary Soto." Background of poet Gary Soto‘s early life in a poor working-class Mexican American community. Cultural loss and marginalization.
"The Levee." Gary Soto.
"Hand Washing". Gary Soto.
Story, "newborn thrown in trash and dies." John Edgar Wideman. Inevitability of a premature death.
Poem, "How to Write the Great American Indian Novel". Sherman Alexie. A clever satiric poem about how whites co-opted Indian culture, resulting in the metaphoric and actual disappearance of a people.
Susan Power. Short story, "First Fruits." Using actual history of the first Indian who was educated at Harvard University, this imaginative story by an author of American Indian heritage brings American Indian culture and contemporary American majority culture into harmony and preserves the cultural identity of the Indian protagonist.
Session 3. Film
[second paper due]
I’ve used several films over the years, most recently, The Station Agent.
Alexie, Sherman. "How to Write the Great American Indian Novel". In Native American Songs and Poems (NY: Dover) 1996, pp. 28-29.
Anzaldua, Gloria. Borderlands/La Frontera (San Francisco: Aunt Lute Books) 1987
Auden, W. H.."Surgical Ward". In The Collected Poems of W. H. Auden (Kingsport, TN: Random House, 1945)
Baca. Jimmy Santiago. A Place to Stand: The Making of a Poet (New York: Grove Press) 2001.
Ball, Tamara Dale. "Search for wholeness: the adventures of a doctor-patient." The Pharos. 54 (1): 28-31 (Winter, 1991).
Berlin, Richard. "Open You Up" by. In How JFK Killed My Father (Long Beach: Pearl Editions) 2004, p. 10
Broyard, Anatole. "The Patient Examines the Doctor". In Intoxicated by My Illness (New York: Clarkson Potter) 1992, pp. 33-58
Bulgakov, Mikhail. "The Steel Windpipe". In A Country Doctor’s Notebook (London: Collins and Harville Press) 1975, trsl. Michael Glenny
Campo, Rafael. "The Distant Moon, I, II,III, IV". In The Other Man Was Me (Houston: Arte Publico Press) 1994, pp. 113-115
Campo, Rafael. "It Rhymes with ‘Answer’ " In The Poetry of Healing: A Doctor’s Education in Empathy, Identity, and Desire (New York: W. W. Norton) 1997, pp. 222-254.
Charon, Rita. Narrative Medicine: Honoring the Stories of Illness (New York: Oxford University Press) 2006
Chesney, Gregg. "Apparition" In Body Language: Poems of the Medical Training Experience, Jain, N., Coppock, D., Brown-Clark, S., eds. (Rochester, New York: BOA Editions) 2006, p.27
Cisneros, Sandra. "Original Sin". In Loose Woman (Vintage Books: New York) 1994, p. 7
Clifton, Lucille. "In the inner city". In Good Woman (Brockport: BOA Editions) 1987, p. 15
Condit, Celeste. "How Culture and Science Make Race 'Genetic': Motives and Strategis for Discrete Categorization of the Continuous and Heterogeneous". Literature and Medicine V. 26, No. 1 (2007) pp. 240-268,
Coulehan, Jack. "I’m Gonna Slap Those Doctors". In Blood and Bone, eds. Angela Belli and Jack Coulehan. (Iowa City: University of Iowa Press) 1998 p. 21
Coulehan, Jack. "You Say Self Interest, I Say Altruism." In Professionalism in Medicine: Critical Perspectives, eds. Delese Wear & Julie M. Aultman (New York: Springer) 2006, pp. 103-128
Davis, Philip and Bradley, John. "The Meaning of Normal." In What’s Normal? eds. Carol Donley and Sheryl Buckley (Kent, OH, London: Kent State University Press) 2000, pp. 7-16.
Dickinson, Emily. "Much madness is divinest sense". (No. 435)
Dubus, Andre. "Liv Ullman in Spring". In Meditations from a Movable Chair (NY: Alfred A. Knopf) 1998.
Duffin, Jacalyn. "Technology and Disease: The Stethoscope and Physical Diagnosis". In History of Medicine: a Scandalously Short Introduction (Toronto: University of Toronto Press) 1999, pp. 191-208.
Ferguson, Laura. The Visible Skeleton Project. Perspectives in Biology and Medicine, 47/2: 159-175, 2004
Ferris, Jim."The Coliseum." In The Hospital Poems (Charlotte, NC: Main Street Rag) 2004, p. 42
Fiser, Karen."Across the Border". In Words like Fate and Pain (Cambridge: Zoland Books) 1992, p. 3
Gawande, Atul. "The Case of the Red Leg." In Complications: A Surgeon’s Notes on an Imperfect Science (NY: Metropolitan/Henry Holt) 2002, Pp. 228-252.
Gawande, Atul. "Naked". New England Journal of Medicine, 353:7, August 18, 2005, pp. 645-648
Gunn, Thom. "Save the Word". In Boss Cupid (New York: Farrar, Straus & Giroux) 2000
Halpern, Jodi. From Detached Concern to Empathy: Humanizing Medical PracticeA (New York: Oxford University Press) 2001
Henningsen, Gail R. "What We Don’t Know." The Bellevue Literary Review, Fall 2004 (4/2) pp. 76-85
Hoagland, Tony. "Emigration". In Sweet Ruin (Madison, Wis.: University of Wisconsin Press, 1992)
Iezzoni, Lisa. "Blocked." Health Affairs, 27/1, 203-209 (Narrative Matters), 2008
Iezzoni, Lisa and Freedman, Vicki A. Turning the Disability Tide: The Importance of Definitions. JAMA, Jan 23, 2008. V.299, NO. 3, pp. 332-334.
Jacobs, Michael. "Falling Through" by. In Body Language: Poems of the Medical Training Experience (Rochester, New York: BOA Editions) 2006, p.49
Jauhar, Sandeep. "Heart Rhythms". In Intern: A Doctor’s Initiation ( New York: (Farrar, Straus and Giroux) 2008, pp. 95-99
Klass, Perri. Baby Doctor (New York: Random House) 1992
Lee, Don. "About Gary Soto." Ploughshares Spring, 21/1: 188-192 (1995).
Levin , Meryl. Anatomy of Anatomy (New York: Third Rail Press) 2000.
Mairs, Nancy. "On Being a Cripple". In Plaintext (Tucson: the University of Arizona Press) 1986, pp. 9-20
Manning, Lynn. "The Magic Wand". From Staring Back: The Disability Experience from the Inside Out, ed. Kenny Fries. (New York: Plume/Penguin) 1997
Mates, Susan Onthank "Laundry". In The Good Doctor (Iowa City: University of Iowa Press) 1994, pp. 9-14.
Moore, Lori. "People Like That Are the Only People Here: Cannonical Babbling in Peed Onk." In Birds of America (New York: Alfred A. Knopf) 1999
Mueller, Lisel. "Monet Refuses the Operation". In Alive Together: New and Selected Poems.(Baton Rouge: Louisiana State University Press) 1996, p. 186
Pastan, Linda. "Routine Mammogram". In Carnival Evening. New and Selected Poems: 1968-1998. (W. W. Norton: New York and London) 1998, p. 134
Pope, Robert. Illness and Healing: Images of Cancer (Hantsport, Nova Scotia: Lancelot Press) 1991
Power, Susan. "First Fruits." In Roofwalker (Minneapolis: Milkweed Editions, 2002), Pp. 111-137.
Prince- Hughes, Dawn. Songs of the Guerrilla Nation: My Journey through Autism (New York: Random House/Harmony) 2004
Rios, Alberto. "Day of the Refugios". In The Smallest Muscle in the Human Body (Port Townsend: Copper Canyon Press) 2002
Ritchie, Elspeth Cameron "Language Barrier". In On Doctoring. (New York: Simon & Schuster) 3rd ed, 2001 eds. Richard Reynolds, John Stone, Lois LaCivita Nixon, & Delese Wear, pp. 378-379
Said, Edward. Orientalism. (1978). 1994 Reprint. (New York: Vintage Books) p. 54
Said, Edward W. "Reflections on Exile." Reflections on Exile and Other Essays (Cambridge: Harvard University Press) 2002.
Scannell, Kate. "Sleeping with the Fishes". In Death of the Good Doctor: Lessons from the Heart of the AIDS Epidemic (San Francisco: Cleis) 1999, pp. 23-48.
Soto, Gary. "The Levee." New and Selected Poems (San Francisco: Chronicle Books) 1995
Soto, Gary. "Hand Washing". Junior College (San Francisco: Chronicle Books) 1997
Stone, John. "Gaudeamus Igitur". JAMA, 249: 1741-1742 (1983)
Stone, John. "The Good-bye, Good-Morning, Hello Poem". In Where Water Begins (Baton Rouge: Louisiana State University Press) 1998, p. 16
Stone, John. "Talking to the Family". In Blood and Bone. eds. Angela Belli and Jack Coulehan (Iowa City: University of Iowa Press) 1998, p. 79
Straus, Marc J. "Red Polka Dot-Dress". In Symmetry (Evanston: TriQuarterly Books/Northwestern University Press) 2000, p. 6
Straus, Marc J. "Monday". In Symmetry (Evanston: Triquarterly Books) 2000, p. 38
Transue, Emily R. "Internship in Seattle" In Body Language: Poems of the Medical Training Experience, Jain, N., Coppock, D., Brown-Clark, S., eds. (Rochester, New York: BOA Editions) 2006, p.89
Temple, L.F.K., McLeod, R.S, Gallinger, S., and Wright, J.G."Defining Disease in the Genomics Era". Science. 293/3 August, 807-808 (2001)
Updike, John. "From the Journal of a Leper". In Problems and Other Stories (New York: Alfred Knopf) 1976.
Verghese, Abraham. The Tennis Partner (NY: Harper Perennial, 1999) (HarperCollins, 1998)
Watts, David. "Physical Exam". In Taking the History (Troy, Maine: Nightshade Press) 1999.
Welch, H. Gilbert, Schwartz, Lisa and Woloshin. Steven. "What’s Making Us Sick Is an Epidemic of Diagnoses". New York Times, Science Times, January 2, 2007
Wendell, Susan. The Rejected Body: Feminist Philosophical Reflections on Disability (New York and London: Routledge, 1996
Wideman, John Edgar. "newborn thrown in trash and dies." In All Stories Are True (New York: Pantheon/Vintage) 1992. pp. 120-128.
Williams, William Carlos. "The Use of Force". In Robert Coles, ed. The Doctor Stories. 1984
Yalom , Irvin D."Fat Lady". In Love’s Executioner (New York: Harper Perennial) 1989, pp. 87-117.
Zuger, Abigail. "Learning to Care for Patients, in Truest Sense". New York Times, 11/27/01