Let The Living Teach Physicians About Healing

April 12, 2009 at 8:59 pm

A physician watching over a sick child.
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

In a recent op-ed piece in the New York Times ("Dead Body of Knowledge") Christine Montross made a plea to continue the long tradition of cadaver dissection in medical education.A Montross, a physician and author of the thoughtful book, Body of Work: Meditations on Mortality from the Human Anatomy Lab, argues that anatomy courses based on human dissection offer "a safe and . . . gradual initiation into the emotional strain that doctoring demands." She is concerned that recent trends to incorporate advanced imaging techniques into the anatomy lab may even replace dissection completely and believes that medical students will miss out on the emotional conditioning that human dissection provides. A few days later the New York Times published six letters to the editor responding to Montross’s essay — all of them written by medical professionals or medical students. Five of the six letter writers supported Montross’s position, but a Stanford University professor disagreed, stating that "teaching anatomy cannot be couched in an either or framework; instead, technology and cadavers should enhance each other." I agree with the Stanford professor and here argue that dissection of a preserved cadaver, while it has much to offer for medical education, is not a teaching tool to help physicians and other health professionals "cope" with the emotional demands of working with sick and dying human beings. It has, to the contrary, been noted that the inevitable objectification of the body that takes place as the cadaver is dissected during months of anatomy teaching, marks the beginning of the developing physician’s professional detachment — a detachment that needs to be unlearned and guarded against so that it does not interfere with appropriate care for patients.

Writes one student during her anatomy course, "I can see how easy it is for health professionals to focus on the body and not on the person" (p. 38, Anatomy of Anatomy in Images and Words, by Meryl Levin). And another writes, "I suppose I have become comfortable, or at least reconciled to the reality of the next 10 weeks. I don’t like that. I don’t like that I have stopped truly thinking about the experience, because there is still a lot to think about. These cadavers did once live, breathe, eat, and sleep before they so graciously donated their bodies to medicine" (p. 58, Anatomy of Anatomy). These thoughtful comments were written by anatomy students who volunteered to participate in a project that photojournalist Meryl Levin initiated several years ago, culminating in her book, Anatomy of Anatomy in Images and Words. The students wrote journal entries during their anatomy course, which forced them to reflect on their experience. Most medical students do not participate in such ongoing reflective exercises while they take gross anatomy, or even after they complete the course. Even the memorial services that are often held at the end of anatomy classes do not address the problem of professional detachment and certainly do not address questions of how to interact with dying patients and their families. Following such a memorial service, one student noted that "I found it hard to become very emotional about these prosections, these bodies, these individuals, these first patients of mine. Maybe I am on my way to acquiring some of the tools I will need to become a physician — a scary thought though, because that is not the kind of physician that I would like to become. . . . must we have a memorial service each time we encounter death in some form or another? It worries me a little that we (or I) needed the service to step back for this all-important reflection, something so many of us could not or would not have done on our own, individually. Hopefully dealing with death will be different — not easier, just different — the next time around" (p. 124, Anatomy of Anatomy).

There are, it is true, some medical schools that nowadays recognize the problem of professional detachment and its early beginnings in the experience of intensive cadaver dissection in the gross anatomy lab. Most notable among them is the University of Massachusetts Medical School, which, under the guidance of anatomy instructors and thanatologist, Sandra Bertman, work with students to help them recognize and articulate (verbally and in drawings) their own fear of sickness and death and other implications of working on the dead-see annotations of Facing Death: Images, Insights and Interventions, and One Breath Apart: Facing Dissection, Bertman’s books detailing this approach.

But what will dealing with death be like when it happens to a person the physician has been treating? The artificially preserved cadaver of the anatomy lab cannot be equated with the complex physiologic and emotional processes of becoming sick and of dying, and its dissection cannot be equated to working with suffering or dying patients and those who love them. The cadaver is a static entity, a representation of what once was, not a process that the student has witnessed as it was unfolding. Newer imaging techniques at least allow observation of some body processes, even if they do not provide the emotional substrate for that body and its interactions with others. Although students may project their fears onto the cadaver, the cadaver cannot help them to negotiate the needs of unpredictable and changeable human beings-human beings who, as physicians, they will come to know, however fleetingly. That negotiation can only be learned about and confronted by working with the living and continually reflecting on that work. Generations of medical students have, after all, learned anatomy from cadaver dissection, but physicians have been criticized for failing to engage with dying patients and their families. It is the incorporation of a medical humanities perspective into all phases of medical education, not cadaver dissection per se, that attempts to address such problems.

Bertman, Sandra L. One Breath Apart: Facing Dissection (Newton, Mass: Ward Street Studio) 2007

Bertman, Sandra L. Facing Death: Images, Insights, and Interventions (Washington, Philadelphia, London: Hemisphere) 1991

Levin, Meryl. Anatomy of Anatomy in Images and Words (Third Rail Press

The Mirror and Self-Knowledge

January 22, 2009 at 10:22 am

Using the internet for self-knolwedge

Commentary by David Biro, MD, PhD, Assistant Clinical Professor of Dermatology at SUNY Downstate Medical Center and author of One Hundred Days: My Unexpected Journey from Doctor to Patient. His new book, The Language of Pain, will be published by Norton in 2009.

Illness like any experience that deviates from the norm (in this case, the norm of health) triggers a search for meaning: something is wrong with me, I must find out what is happening. Since the source of illness lies within us, we instinctively turn to introspection: let's try to see what's happening. But immediately we encounter obstacles. There is the opaque surface of the body that literally prevents us from seeing inside. And more significantly an entire nervous system designed specifically to limit (thankfully) our engagement with the body and continually point us in the opposite direction. Even consciousness - that quintessentially inner and private realm - constantly reaches outwards towards the objects in the external world that we think about, desire, and fear.

While not explicitly offering illness as a case-in-point, many contemporary thinkers including Sartre, Foucault and Lacan have consistently undermined the traditional approach to self-knowledge by introspection. Instead, they emphasize the importance of the Other in understanding the self. We rely, for example, on other people like doctors, who, in turn, have studied other bodies (both dead and alive). We rely on things like books and the Internet which provide information about ourselves. And of course we rely on that ancient means of self-reflection, the mirror, which allows us see ourselves from perspectives otherwise unobtainable.

The Case of Frigyes Karinthy

Frigyes Karinthy was a well known Hungarian writer of the early 20th century who developed a brain tumor. The tumor, however, would not be diagnosed by one of the many specialists he consulted with but rather quite remarkably by himself, a layman who never went to medical school. Himself, that is, with the help of a metaphorical mirror.

The first sign of trouble came with the trains roaring in his head. Next the sense that pictures and tables were moving when they weren't. Then there were headaches and fainting fits. One doctor attributed the symptoms to an ear infection. Another to nicotine poisoning and a third to humiliations suffered in early childhood. In each case none of the prescribed interventions helped, and for a while Karinthy was determined to live with the trains and hallucinations, belittling their importance as his doctors did. But when they persisted and new symptoms developed, he could deny them no longer. They were interfering with every aspect of his life. Regardless of what the doctors thought, something was wrong. Very wrong.

Proof of his conviction would come unexpectedly. Karinthy was visiting the clinic where his wife, a doctor, worked at the time. Accompanying her on rounds, Karinthy stopped at the bed of a young man, transfixed by the expression on his face. It looked familiar, he thought. The man has a brain tumor, his wife grimly informed him, and is terminal. Ah, remembered Karinthy, he had seen that face before, in a friend who died many years ago of the same condition. But Karinthy wasn't entirely satisfied. He continued to be haunted by the sight. It reminded him of someone else too, he was sure.

Later on it hit him with the full force of the roaring trains in his head:

I had suddenly stopped dead in the gateway, like the ox I had seen unwilling to enterA the slaughter-house. At that moment, it had flashed into my mind. I remembered. The pale, vacant face of the dying man reminded me of my own expression as I had seen it lately in my mirror while shaving. I took two steps, then stopped again. With a foolish grimace, like a man who pretends to belittle some achievement he is boasting about, I said to my wife: "Aranka, I've got a tumor on the brain."(1)

Aranka dismissed her husband's epiphany as crazy. But she was soon proven wrong. Fortunately, things would turn out well for Karinthy. He was successfully operated on by the famous Swedish neurosurgeon Olivecrona. Afterwards, he returned to his writing career and publish his best work yet, a memoir of his fascinating encounter with illness, A Journey Round My Skull.

Doppelgangers in Pain

Karinthy is not unique in deriving insight about his illness from another person. Many patients instinctively gravitate toward other patients with similar diagnoses. How is illness playing out in them and what in turn might it mean for me? Indeed, this is a recurring theme in the increasingly popular genre of illness narrative or pathography. Whether they find fellow sufferers in the clinic or in support groups or on the Internet, patients are constantly on the lookout for what Alphonse Daudet, another writer-patient, once called his "doppelgangers in pain."

On the one hand, these significant others are an instant source of support and sympathy in a world that tends to alienate and isolate the sick. "My doppelganger," writes Daudet during his stay at a French sanatorium, "the fellow whose illness most closely resembles your own. How you love him, and how you make him tell you everything!" At the same time, they offer a vital means to self-knowledge. Towards the end of his life, Daudet could no longer walk steadily. The ataxia caused by syphilitic damage to his cerebellum resulted in a clumsy, halting gait. But the only way for him to see what he looked like was to observe himself in a mirror. Or better yet in another patient with the same problem:

I see him in my mind's eye, putting one foot down carefully before the other, but still tottery: as if walking on ice. Sad. (2)

No doubt Daudet feels sad for his doppelganger. But equally sad, perhaps more so, for himself and what has become of him.

Nor do sufferers restrict "finding" themselves in human beings that literally look like them. Grieving the loss of his lover who died of AIDS, Mark Doty finds solace and insight from a seal he spies in Cape Cod Bay during a walk. Apart from the group and alone, distressed and exhausted, the seal "conveys a kind of helplessness and desolation" that cuts Doty to the core. Not only because he feels sympathy for another sufferer but because he sees himself in the seal, the inside of his grief-stricken mind suddenly visible (3). Others find themselves in the fictional characters of books they read, in the cadences of songs they listen to, and in the sky that seems to mirror their emotions. All of which should be understood not as a passive "stumbling" upon the self but as an activity that requires a degree of imaginative or metaphorical work on our parts. We project ourselves onto things in the world - other people, seals, or songs -so we that could see and understand ourselves.

Mirror Neurons

As it turns out, the human brain may be hardwired to engage in projections of this sort. One of the most exciting, recent discoveries in science has been the mirror neuron. First isolated in monkeys and later found to exist in human beings, these neurons (and groups of neurons) are active not simply when we are moving and emoting but when we observe others moving and emoting. Our brains, as it were, re-enact or mirror the movements and emotions of other people as we watch them. Although scientists are still working out the implications of this extraordinary finding, it is almost certain that the brain's mirroring system contributes to the profoundly social nature of human beings and may well be responsible for many of our greatest collective achievements: language, social institutions, and culture (4).

Many scientists also believe that neuronal mirroring can reflect in two directions, illuminating both the external world (of others) and the internal world (of self). By constantly observing and imitating others, we not only learn about them but about ourselves: How we see and think of ourselves; the meanings we ultimately give to our most intimate and "unsharable" experiences like pain; indeed the ongoing project of human creation in general as it works to fill the world with things that possess the capacity to reflect our humanity (5).

Thinkers like Sartre, Foucault and Lacan may have been exquisitely prescient. Mimesis may well turn out to be a prerequisite or stepping stone to self-knowledge. We observe, reproduce, impose patterns, and thereby understand. We can do this with objects that happen to cross our field of vision like the patient encountered by Friges Karinthy or the seal by Mark Doty. But we could also do this on a more sophisticated level. If a potential doppelganger doesn't exist we can invent one. As Alphonse Daudet does in his dream of the boat with the damaged keel (mirroring his diseased keel-spine). And as many artists do in their poems and paintings. After finishing his masterwork, Flaubert is famously reported to have said of his creation: Emma Bovary, ces't moi. The re-production leads to recognition. The same thing that painters do perhaps more self-consciously in their self-portraits and in the case of Frida Kahlo, her double self-portraits. Here the dictum of philosopher Nelson Goodman is most transparently realized: Comprehension and creation go on together (6).


(1)Friges Karinthy, A Journey Round My Skull (London: Faber and Faber, 1938), p.59
(2)Alphonse Daudet, In the Land of Pain (New York: Knopf, 2002), p.56-7.
(3)Mark Doty, Heaven's Coast (New York, HarperCollins, 1996)
(4)Marco Iacobini, Mirroring People: The New Science of How We Connect with Others (New York: Farrar, Strauss and Giroux, 2008)
(5)Elaine Scarry, The Body in Pain (New York: Oxford, 1985)
(6)Nelson Goodman, Ways of Worldmaking (Indianapolis: Hackett Publishing, 1978)


A Time For Celebration And Contemplation: Inauguration Day, 2009

January 18, 2009 at 3:49 pm

Fireworks exploding in the night sky over Newcastle

Commentary by Felice Aull, Ph.D., M.A., Founding editor, Literature, Arts, and Medicine Database and editor, this blog.

It seems these next few days require a blog entry that digresses from our usual sequence of invited essays. The moment is of course historic. The moment is exhilarating. The moment is sobering.

In an earlier commentary, written just before Barack Obama was nominated to be the Democratic candidate for president of the United States, I invoked his candidacy and family background to draw attention to the fallacy of race as a biologic concept, and to problematize ongoing efforts toward race-based medicine. Now I invoke the onset of Obama’s presidency not only to celebrate his achievement and the barriers that have been broken, but also because he is an author, an educator, a thinker who does not see the world in Manichaean terms, and who counts among his friends a poet’s poet —Elizabeth Alexander, the scholar he asked to write an inauguration poem. I think I can even relate this moment to medical humanities!

I am now reading Obama’s autobiography, Dreams from My Father, published in 1995. I’m only up to chapter 5, but it is clear that this man, long before he sought the presidency, was self-reflective and could articulate the complexity of his personal feelings as well the complexity of the social dilemmas he was forced to confront. Aren’t these insights and skills what we in medical humanities are trying to encourage? How refreshing to have such a person heading our government.

How refreshing, also, that the President-elect chose a contemporary who is an award-winning poet, a scholar in African American and American studies (who will chair the department of African-American studies at Yale University later this year), and who has been honored by Yale for her teaching abilities. Here are the last few lines of one of her poems:

Poetry (and now my voice is rising)

is not all love, love, love,
and I’m sorry the dog died.

Poetry (here I hear myself loudest)
is the human voice,

and are we not of interest to each other?

from Ars Poetica #100: I Believe
In American Sublime

Are we not of interest to each other? Such also is the work of medical humanities-to be interested in, listen to, and hear the other.

Borderlands: A Theme and Syllabus for Medical Humanities Teaching

November 14, 2008 at 3:48 pm

Hands reaching out

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
Medical uncertainty

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

Problematizing normality

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
Matuschka Archive
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
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Trekking And The Medical Humanities

September 13, 2008 at 10:35 am

Trekking through the Himalayas

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


Nepal, trekking, and new perspectives

In a previous commentary for this blog I wrote about the development of medical humanities modules in two Nepalese medical schools. In this article I aim to pen my thoughts about trekking in Nepal and the Medical Humanities (MH). Nepal is a small country in South Asia surrounded by two of the most populous countries in the world - China and India. Nepal has among the greatest altitude variations of any country on Earth. The land rises from the flat plains of the 'terai' to Mt. Everest, the highest point on the planet within a distance of 150 km. The hills and the mountains of Nepal are a trekker's paradise and attract people from a number of countries. The unspoiled villages, green hills, verdant valleys and soaring Himalayas are the major attractions. The present population may be somewhere between 27 to 30 million. A number of ethnic groups inhabit the land and more than 500 different languages and dialects are spoken.

How can trekking be related to the humanities? On first glance these two appear very different. MH is an intellectual activity and is pursued by medical students, medical teachers and others to obtain a perspective on the human and humane side of medicine. Trekking is a tiring physical activity where you tramp up and down hills, cross streams and endure cold, heat, sweat and grime. Trekking basically is about freedom and following a simpler and gentler way of life at least when you are on the trek. Karl Benz's motor car is absent and the gently rising middle hills with their river valleys have to be traversed on foot. The air is pure, the light magical, the people friendly and you have stepped back a few decades in time! You follow the rhythms of nature. You go to sleep soon after sunset and wake up with the first light of dawn or even before. Many of the illnesses of civilization are the result of leading a lifestyle not in tune with nature's clock. MH in my opinion searches for the simple in disease and health. This is becoming a difficult task in an increasing complex world and trekking may be of some help!

The landscape can stimulate creativity among the students and inspire them to reflect on life, relationships and death from a 'different' perspective. Also exposure to the legends, voices and rich oral traditions of the mountain villages can enrich the writing and other creative skills of students and faculty. These stories, paintings and other art objects can serve to explore a number of issues in the humanities.

Medical humanities retreats

Trekking regions could be a location for weekend MH retreats. In the Dalhousie University, Canada, weekend retreats in the beautiful Canadian countryside are common during the MH module. In Nepal, the trekking areas can serve a similar function. Cities like Kathmandu and Pokhara have the Langtang/Helambu and the Annapurna trekking regions at their door step and students and faculty can easily trek to some of the nearby villages. Many other cities in the plains also have hill towns nearby. The trekking regions have over the years built up good infrastructure and facilities. Sitting in the dining room of a lodge by a roaring fire as the mist settles in for the evening can be a delightful experience for students and faculty and can lead to a closer and more informal relationship between them. The student-teacher relationship is relatively hierarchical and authoritarian in Nepal and trekking can lead to a more egalitarian and friendly relationship that may be more conducive to learning the humanities.

A cultural and social journey

Most treks in Nepal start in the middle hills though these days roads are making greater inroads. The road head is usually a congested and noisy small town and you can study a village slowly urbanizing. An interesting phenomenon with MH implications! People may either trek alone, with a porter or with a group. The porter is usually a farmer from the hills and it is an interesting experience to walk along this person for days on end. You are offered a different perspective on life and the country! Trekking in a group can also introduce you to other members from a different region or even from a different country.

The middle hills are welcoming with bright sunshine and villages mainly inhabited by the Brahmins and Chettris, the dominant castes in Nepal. Education is becoming more widespread and you can watch children race along the trail to their schools, the same steep trail where you rest and catch your breath after every two steps. As you go on the valley gradually becomes narrower and the river flows through a deep gorge and the terrain becomes increasingly rocky. Magnificent waterfalls and dense forests create an enchanted atmosphere. The going is tough but the reward is great! After a few days travel you reach the dry Tibet-like valleys behind the Himalayas. These are mainly inhabited by Bhotia communities of Tibetan extraction. This is a classic description of the Around Annapurna, Around Manasulu or even the Everest trek from Jiri. However, you can also fly in to a remote airfield and then start your trek. There are also shorter treks for those short on time.

Difficulties in accessing health care, and the modalities followed by the inhabitants to cure disease and protect health are important issues for the Medical Humanities. Because of the mountainous terrain, the volatile and unstable political situation with its prolonged conflict and poor socioeconomic development, modern health care may sometimes be many days walk away. Complementary Medical practitioners and faith healers often fill in the yawning gap for health care. Thus complementary medicine, rising standard of living, increasing number of trekkers and access to medical care are closely interlinked.

Access to health care, standard of living, and complementary medical systems

Many of the villages are situated one or two days walk from the nearest road head and to reach them you have to walk up and down winding trails through the hills. You can see first hand the important role complementary practitioners play in providing health care. Sick persons are also often carried in baskets on the back of sturdy village porters to the nearest health centre or hospital. The basket is often called the 'hill ambulance'.

The main trekking areas have seen a rise in the standard of living along with westernization and a change in the outlook. The approach to illness and its treatment is also changing. Western medicine is being more widely accepted and westerners (even trekkers) are regarded as doctors and experts in modern medical care. The farmers are able to supplement their income through the cash earned from trekkers and the traditional subsistence village economy has been replaced by a cash one. The overall health status has improved but the diseases of civilization are slowly beginning to make an appearance.

In the middle hills, Hinduism is the main religion and ayurveda and herbalism are the main medical systems. Faith healing is also common. In the gorges, the Buddhist influence becomes stronger and shamans become the main faith healers. In the trans-Himalayan valleys, Tibetan medicine dominates and the practitioners called 'amchis' cater to the healthcare needs. Modern allopathic health centers and hospitals are also present in a few areas mainly manned by paramedics. The process of creation of an indigenous medical system, its interaction with other medical systems and with western allopathic medicine (which came from the cities) can be a fascinating subject of study. The complementary systems offer a different perspective and while not always scientifically rigorous like the allopathic system may be more holistic considering man in the perspective of the cosmos.

Progress made

In the recent decades tremendous progress in healthcare indicators and access to health care has taken place. Education is becoming widespread among the younger generation. The importance of clean drinking water, sanitation, proper sewage disposal is becoming evident to the rural and the underprivileged urban populace. A number of health centers, health posts and subhealth posts (institutions delivering primary health care) are being set up and both doctors and paramedical workers are looking after the health of the population. Community hospitals and dispensaries have been set up in many areas and good quality medicines are being manufactured in the country. Nepalese manufacturers now meet more than 40% of the country's requirements and this proportion will increase in the future. Students can see first hand these changes in the rural areas of Nepal. These changes are also present in urban areas but are more dramatic and easier to study in the rural areas.

Humanities issues of particular concern to Nepal

The major humanities issues of particular concern to Nepal in my opinion are to encourage a caring attitude towards patients, taking into consideration the patients’ weak socioeconomic conditions in treatment decisions; help patients make proper decisions about treatment and health care; promote service in rural and underprivileged areas; play a role as a motivator and an agent of change in rural communities; develop good working relationships with complementary medicine practitioners and involve them in making healthcare accessible to the underprivileged; and adapt western allopathic medicine to a traditional setting. Many of these issues may also be applicable to other countries in South Asia.

Thus trekking can serve to introduce, highlight and underline a number of MH issues in the Nepalese context. The exposure to fresh air, fresh food and an unhurried pace of life can do wonders for the mental and physical health of the students and faculty. The unhurried environment allows for deep reflection and in depth study of a number of issues. Thus trekking and the humanities may be closely related in the Nepalese context. The challenge is to explore and utilize the connection to the full!

A Medical Humanities Perspective On Racial Borderlands

June 30, 2008 at 10:31 am

Children of various skin colors and 14 DNA profiles in color

Commentary by Felice Aull, Ph.D., M.A.; Associate Professor of Physiology and Neuroscience, New York University School of Medicine; Editor in Chief, Literature, Arts, and Medicine Database

I have long been interested in the metaphor of borderlands as a tool for exploring areas of ambiguity in medicine and in society. Courses that I teach (to medical students) consider ambiguous boundaries between student and professional, patient and physician, personal life and professional life, disease and health, and the cultural confusion that derives from migration and dislocation. I address those issues using theory from the social sciences and humanities in addition to fiction, memoir, poetry, and art. One of the topics that we consider is the ambiguity inherent in concepts of race. This has become a topic of recent interest (and controversy) because race, medical research and practice, and health policy are being linked with the genomics revolution. And since all of these endeavors take place in a sociopolitical context, recent events and discussions in the national political scene cannot help but play a role in our thinking about these topics. With this as background, I offer some thoughts triggered by a recent confluence of events.

The events

1. The presumptive nomination of Barack Obama as the Democratic Party’s choice for president.
2. The March, 2008, announcement that the National Institutes of Health established the Intramural Center for Genomics and Health Disparities, whose priority is to "understand how we can use the tools of genomics to address some of the issues we see with health disparities."
3. Publication in the journal, Literature and Medicine, of "How Culture and Science Make Race ‘Genetic’: Motives and Strategies for Discrete Categorization of the Continuous and Heterogeneous," by Celeste Condit. (26/1, Spring 2007 pp.240-268).

What is race?

Because Barack Obama was chosen to be the presidential candidate of a major political party, much has been made of the advances this country has made in racial tolerance and acceptance. Yet the fact that so much attention is being given to the racial component of the upcoming election emphasizes that race and color are still important in the national narrative. Obama personifies the contradictions and fallacies of the way we traditionally think about race. Born in Hawaii to a "white" American woman and a "black" man from the African country of Kenya, Obama is identified by virtually everyone as "African American" and black, although he is culturally atypical in that he is not descended from US slaves. He himself for the most part accepts that designation but he has consistently sought to move beyond race and has even been described as "post-racial." In this country Obama is virtually forced to identify as African American because he is so identified by almost anyone who notices the color of his skin. Mr. Obama could not identify himself publicly as a white American or as "Caucasian," even though his ancestry is as much white as it is black. He could not "pass" as white, simply because we tend to equate skin color and other physical characteristics with something that many call "race."

While race has recently come to the forefront of national discussion in the political arena, it had already surfaced as a topic of interest among contemporary sociologists, anthropologists, evolutionary biologists, and others who questioned how biomedical researchers were characterizing populations and questioned conclusions that related biologic characteristics to "race." (See for example references 1, 2, 3 below). Already in 1999, the Institute of Medicine stated that race was a "construct of human variability based on perceived differences in biology, physical appearance, and behavior" but race was not a "biological reality." (The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved, p.38 as quoted in reference 1 below). Yet headlines are still being made by researchers who claim to identify genes that "explain" "racial" differences in response to drugs ("Genes Explain Race Disparity in Response to a Heart Drug," by Gina Kolata, New York Times, April 29, 2008).

Race-based medicine

There is much ongoing biomedical research that attempts to establish a genetic basis for biologic differences among populations, especially in the area of pharmacogenetics. Now the NIH is going to "continue efforts to develop genetic epidemiology models and population-genetics research projects that provide insights about the interrelationships of culture, lifestyle, genetics, genomics and health." The director of the new NIH center, Charles Rotimi, is described as leading "research on diseases affecting minority groups." While the word "race" is not used in describing the new institute’s mandate, it is of course a subtext. And while the goal of the research may be to address health disparities, and will take into consideration culture and lifestyle, subtle socioeconomic patterns of discrimination and lack of opportunity in education, employment, housing, etc. are apparently not included as factors that influence complex illnesses — yet they should be. For a recent relevant commentary on this, see Daniel Goldberg’s Medical Humanities blog, "On Income Inequality and Population Health" and also see the "stigma" issue of Social Science & Medicine, that Goldberg drew attention to a few days earlier.

In my teaching I used the recent penetrating article by Celeste Condit in Literature and Medicine (event #3 above) to consider concepts of race and race-based medicine. Condit lays out the background for the current interest in race-based medicine and then proceeds systematically to demonstrate that the complexity of human genetic variation can not be fit into discrete categories like race or what is more often now discussed as continent of origin and gene clusters. She marshals the evidence that "there are no discrete boundaries among groups; instead there are slowly changing [gene] flows" (p. 253). And here is why this essay appeared in a journal of literature and medicine: Condit asserts that language "is always predisposed toward discreteness and binarity" and that we cannot wrap our minds around "any single word or visual map that could capture the 3 million different patterns of difference [in the 3 million base pairs in the human genome that vary]" (250). In addition, Condit argues that the notion that "human genetic variation partitions people into ‘races' " is a two-step [probably unconscious] rhetorical strategy that claims (1) gene clustering coincides with continental boundaries and (2) continents coincide with five historically designated racial categories(254). She shows how verbal manipulation is involved in mapping genetic clusters with five continental groupings and then enumerates the many ways that racial designations fluctuate and do not consistently correspond with the five groupings or with genetic clusters.

I asked students to describe how they were being taught with regard to categorizing patients by race and ethnicity (variably, depending on individual instructors). We discussed the following: Isn’t it important to be able to design targeted drugs and treatments that are based on human genetic variation? Don’t we want to bring the genetic revolution to bear on health disparities among populations? Don’t physicians need to take race/ethnicity into account when they make diagnoses and recommend treatment?

Physicians may make erroneous assumptions about the ancestry of their patients, based on skin color. Even racial self-description is based on social and cultural factors that can have little to do with relevant genetic information- a problem that applies to research as well as to medical practice. For example, the recent paper (Reference 4) that made above-mentioned headlines in the New York Times used a sample repository based on self-identified "ethnicity" and classified its human subjects based on self-reported ethnicity (read "race"). So from a medical research and practice perspective, there are problems of interpretation. Many social scientists and biologists are concerned about these problematic practices because they fear that important socioeconomic factors influencing health will be obscured and the discredited view that race is a real biologic entity will reassert itself, with all of the baggage associated with such a view. Critics of race-based medicine do not dispute the need for targeted therapy and treatment but they urge individual genetic testing, and that researchers develop a "technical vocabulary . . . based on concepts of geographic distance from some arbitrarily chosen orientation" (Condit, p. 263).

Categorizing race/ethnicity for medical humanities

In medical humanities scholarship and teaching, culture, identity, and marginalization are topics of interest. Recognizing this, the editorial board of the online resource, the Literature, Arts, and Medicine Database (I am editor-in-chief) sought to identify authors or artists whose work reflected these topics from the perspective of a particular ethnicity/race. But this turned out to be a vexing proposition. Suppose we were to annotate one of Barack Obama’s books for the Database-should we categorize his ethnicity as part of our brief biographical information? If so, how? Such questions were debated by the Database editorial board at length a few years ago, and probably none of us are totally satisfied with our final decision. The decision was, for the time being, to categorize a limited group of authors who self-identify their ethnicity publicly and whose work reflects their interest in that ethnicity. And I admit that the categories we developed were Eurocentric — that is, whites are the (invisible) referent group against which all others are categorized and which assigns the categories. So, in the case of Obama, we would probably categorize him- as African American-because of ongoing racial discussions about him and his own discussion of race in his book, Dreams from My Father.

But now I give you an example of an author whose biographical information I struggled with several years ago, before we made the guidelines for ethnicity: literary critic, Anatole Broyard (1920-1990). At first I left his ethnicity blank, thinking that he was "Caucasian." Then, after reading Henry Louis Gates’s essay about Broyard in the New Yorker, I labeled him as African American -Gates wrote that Broyard came from a mixed-race Creole background; as an adult Broyard had not revealed that information to most people and was able to do so because he could "pass" as white. Yet I was uncomfortable, thinking that Broyard would probably not have wanted this information to be made public and, in addition, his ethnicity had nothing to do with the work I had annotated. After a while I removed the designation of African American and left his ethnicity blank again. Now we have the book by Broyard’s daughter, Bliss: One Drop: My Father’s Hidden Life — A Story of Race and Family Secrets (Little Brown, 2007), in which she traces back her father’s side of the family and finds in patterns of racial confusion and suppression an explanation for some of his behavior. She has "outed" her father for good (and herself??) and raised these issues for public discussion. Many of us like to see ourselves as "post-racial" and perhaps ethnicity should no longer be a marker for authors — but I don’t think we’re there yet. (I’m still leaving Anatole Broyard’s ethnicity blank.)

1. Sandra Soo-Jin Lee, Joanna Mountain, and Barbara Koenig. The Meaning of Race in the New Genomics: Implications for Health Disparities Research. Yale Journal of Health Policy, Law, and Ethics. Spring, 2001, pp. 33-75.

2. Alexandra Shield, et al. The Use of "Race" Variables in Genetic Studies of Complex Traits and the Goal of Reducing Health Disparities. American Psychologist, Volume 60, Number 1, January 2005, pp. 77-103.

3. Troy Duster. Race and Reification in Science. Science, Volume 307, February 18, 2005, pp. 1050-1051.

4. Stephen B. Liggett, et al. A GR K5 polymorphism that inhibits beta-adrenergic receptor signaling is protective in heart failure. Nature Medicine, 14/5, May 2008, pp. 510-517

Teaching Film: A Perspective From Narrative Medicine

June 13, 2008 at 9:32 am

Film Reels

Commentary by Maura Spiegel, PhD; Associate Professor of English, Columbia University; Core Faculty, Program in Narrative Medicine, Columbia College of Physicians and Surgeons

Maybe it's because classrooms are now routinely video-equipped, or because, as an attention-challenged culture, most of us have come to expect power point or other visual "enhancements" in the lecture hall, or because movies can be so efficient in conveying an idea, or maybe it's simply because we love them so very much, that movies are being used more and more commonly in medical and nursing schools, in Clinical Practice courses as well as Medical Humanities courses. One approach used in Clinical Practice courses is to show short clips of exemplary clinical scenarios from feature films, followed by questions and discussion, and sometimes by role-playing. A favorite teaching text in this context is the 1991 film, The Doctor (dir. Randa Haines). A didactic film, The Doctor tells the story of Jack McKee, played by William Hurt, a highly skilled surgeon with a lousy bedside manner, superficial relationships with his colleagues, a troubled marriage and a frail connection to his young son. In the course of the film Dr. McKee is diagnosed with and successfully treated for laryngeal cancer, and as a result of this experience, he changes, develops a new sense of empathy, improves his relations not only with his patients and colleagues, but with his wife and son.

A Topical Approach To Teaching The Doctor

Matthew Alexander has developed a series of ingenious and doubtless effective exercises to teach The Doctor (see his article, "The Doctor: A Seminal Video for Cinemeducation"). He excerpts scenes from the film that exemplify the insensitive surgeon's behavior in a large teaching hospital. In one such scene where Dr. McKee makes attending rounds, he and his residents enter the room of a young male survivor of a suicide attempt. When they enter, McKee subtly gestures to the chaplain who is talking to the boy, to take his leave so that the doctors can do their work. The chaplain promptly gets up and makes an exit. After the doctor bombards his residents with questions to which they eagerly respond, McKee gets around to asking the patient (who had jumped from a fifth floor window) how he's doing. In response to the boy's expression of shame at his failed suicide, McKee advises him that "next time" if he wants to "inflict some real punishment on himself" he should "try golf."

After screening the clip, Alexander poses the following questions:
1. What is your experience of hospital hierarchy?
2. What are some ways that teaching rounds can be done to be sensitive to patients' needs for privacy and respect?
3. When is humor appropriate in the medical setting? When is it not appropriate?

Another short scene presents Dr. McKee and his attractive wife (Christine Lahti) in their car returning home late one evening for a quiet dinner. When he receives and answers a page, his wife expresses mild frustration.

Matthew Alexander's discussion questions:
1. What stereotypes does this clip reflect about the medical marriage?
2. What are some common challenges faced by physicians in balancing their work and home lives?
3. What strategies can physicians employ to protect personal time?

I expect that these exercises generate meaningful discussion and a productive exchange of practical approaches to real-life concerns. Without discounting the value of this use of the film, a Narrative Medicine approach to a film like The Doctor differs sharply in strategy and objectives.

A Narrative Medicine Approach To Teaching The Doctor

We undertake a discussion of the film as whole, as a story, using narrative skills to examine the characters, their trajectories, to follow their stories and engage them within their narrative context before drawing connections to the viewer's context. (A narrative skill we all bring to movie-watching is holding details of the story in mind that may not become meaningful until later in the story while responding to what's happening in the moment. Part of our task is exploiting that skill.)

A premise of Narrative Medicine is that attentiveness to how stories are told can make you better at considering a patient's story -or another caregiver's story or your own. It can help you identify what pieces of the story might be missing, what more you'd like to know, or what doesn't seem to fit. Noticing where a story begins and ends, who's included in the story, whether or not it runs along a familiar plot line, how the teller's affect changes in the course of the telling, etc., these are habits of mind for some people and acquired skills for others.

A discussion of The Doctor in a Narrative Medicine context might go in any number of directions. Unlike the exercises above, we would not rely upon isolated clips but rather would present the entire film with discussion to follow. The discussion might begin with the question:

What happens to Jack McKee in the course of the film?

[And here I offer a sort of simulation of the kinds of answers that might emerge in discussion]

McKee allows himself to feel and recognize his own genuine vulnerability, to admit to feeling afraid and to needing others. Early in the film, after his diagnosis, we see that he cannot tolerate his need to be cared for; indeed, such feelings enrage him; he demands that people stop giving him "those caring looks;" he shuns a colleague's offer of sympathy; he isolates himself from his wife after belatedly informing her of his diagnosis.

A facilitator might then pose the question:

Does the film suggest that this inability to tolerate his own needs and desires to be cared for might be tied in some way to his identity as doctor or more specifically as a surgeon?

And here someone might comment on the cliche idea of surgeons being macho, and this could lead to a discussion of cliche in the film more broadly. Someone might object that in fact being a surgeon requires a certain kind of confidence and that the specialty attracts a certain personality type. Another might suggest the film portrays Jack McKee as not just confident but smug -and heavily defended against feeling too much for his patients. Here someone might remind us of some of McKee's comments to his students, such as his observation that the unnatural act of cutting into someone's body requires the dampening of "natural feeling," or, even more to the point, his assertion to his students that caring can interfere with a surgeon's judgment. And here the further observation might arise that in medicine we sometimes encounter a hostility to introspection altogether -as feminizing or "touchy-feely," or a sign of vulnerability that is institutionally disallowed.

At what point are these strategies of McKee's presented as problematic?

For one thing, the filmmaker allows us to see the negative effect of his manner on patients, how they feel degraded, mocked, unseen. His behavior toward a nurse he works with is a complicated mix of flattery and insult - as he displays his bravado for her special appreciation. We might then discuss one or more of these scenes in detail.
Does the film present a key turning point for Dr. McKee?

Someone might observe that McKee's suspension of empathy as an effective medical strategy receives its first blow when he is preparing for his biopsy; we observe just how terrified he is -terrified, it seems, of becoming one of those objectified bodies he cuts into. Someone else might point to the wordless sequence that follows upon the announcement of the death the night before of one of the women McKee knows from the Radiation waiting room. After an exchange with his new friend June, a young woman dying of a brain tumor, the camera traces the looks exchanged among the small cohort of patients as they absorb the news that one of them has died. A young man with a tracheotomy struggles to cry; June looks at him, takes in his suffering; the camera moves to take in Dr. McKee, looking too, and looking at June -at her compassion for the young man, her sharing in his sadness. The scene, the free exchange of looks, feelings, recognition, separateness, mutuality, connectedness, lasts a minute or two, ending with McKee, having taken this all in, having really apprehended another's pain, the subjecthood of another, looking down -retreating into himself. We wonder what he is feeling, if he is allowing himself to feel his own pain.

To my mind the empathic reaction to someone's suffering is one of the most powerful film moments, indeed it's a rare image, despite the fact that suffering is so commonly represented in the movies. In this sequence we respond to the face of the suffering and weeping young man, but we respond also to the faces of those who feel for him, who are compassionate him. As viewers we can enter into the subject position or feel with both positions. Witnessing the power of a response to another's suffering or sadness has special poignancy in the medical context (of course). I believe I can make the claim -without unfolding an entire theory of psychological process- that caregivers are sometimes able to process experiences of their own through attending closely and reflectively to such scenes. Such representations of suffering are pliable and in some sense freeing; you can immerse yourself in them because you don't have someone reacting to you. (For more on this idea, see Heiserman, A. and Spiegel, M (2006) "Narrative Permeability: Crossing the Dissociative Barrier in and Out of Films", Literature and Medicine, Vol. 25, no. 2, pp.463-474.)

And finally, how does Dr. McKee's behavior with his patients change in the course of the film?

Before having his own experience as a patient, McKee would not have allowed himself to go near the state of neediness that he himself experienced anticipating his biopsy; instead he would have made a snide joke, as we saw with the suicidal young man. Late in the film, however, we observe Dr. McKee taking in and acknowledging the somber concern of a patient before transplant surgery; he allows the patient recognition and offers a sense of mutuality. We feel McKee apprehending the other -and we sense that in doing so he enhances his own inner world.

Although in some ways a reductive film, The Doctor offers an opportunity not only to discuss the importance and benefits to the patient and to the caregiver, of being present to others and to oneself in this work that is demanding in ways no other kind of work is. But even more significantly, I think, in discussing the film we in fact already advance these aims. That is, being present to others (and to oneself) can be cultivated in the medical setting, but perhaps not with practical exercises (or not with those alone), rather by cultivating groups with a facilitator to discuss films, read together, write together, and listen to one another. In speaking together about what is so strangely unspoken in hospitals,-suffering, sadness and death-caregivers can engage in authentic discussions that create a different space within the hospital. Such discussions can shuffle hierarchies or at least re-inform them, and they can promote the practice of using film or fiction or writing as a resource for self-care. (See Irvine, C. (2009) "The ethics of self-care." In Cole, T., Goodrich, T.J., and Gritz, E. (Eds.), Academic medicine: in sickness and in health. New York, NY: Humana Press.) This may sound like an entirely unrealistic aspiration, except that it is already happening in so many medical centers. An hour once or twice a month can work wonders.

Movies are of course also taught for their topicality. Films that address issues of gender, transgender, sexual orientation, nationality, race, etc. are introduced into curricula to raise awareness and build so-called "cultural competencies." And more and more film is becoming useful to ethicists for examining topics like organ transplants, genetic engineering, end of life issues, etc. where decisions made by characters can be treated as case studies or problem sets.

Narrative Medicine takes up some of these issues (look for forthcoming work in Narrative Genetics, for example) but we differ in our effort to exploit the fact that good movies communicate in how they are told. Calling viewers' attention not only to how a movie makes them feel but to how those feelings are aroused by the filmmaker is another habit of mind we strive to cultivate in caregivers, but I haven't space here to explore this approach.

We also aim to harness the enormous emotional power of movies. Few approaches to film in current film theory take the feelings that attend or that are provoked by film seriously, despite the fact that emotions elicited while watching film feel very real to us. These are emotions with depth, emotions we have felt before, and are inexorably attached to specifics within the narratives of our own lives. In Narrative Medicine we are developing pedagogical strategies for pursuing this relatively unexamined aspect of the movie-watching experience. One of our aspirations is to offer strategies for using movies as tools of introspection.

A literary commonplace (first observed by Aristotle) proposes that we are more prone to sympathize with fictional characters than with real people. Many theories have been floated for why that might be - if it is true -and here is one more: in the psychic world, one might say that making a character fictional is a way of making it real.

Doctors and other healthcare providers need a venue, an opportunity to engage narratives that bring into conscious existence what they encounter day in and day out.

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

March 13, 2008 at 10:46 am

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

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

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

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

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

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

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

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

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

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

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

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

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

What Is Medical Humanities and Why?

January 25, 2008 at 11:25 am

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

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

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

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

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

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

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

Further Reflections on Medical Humanities

December 22, 2007 at 3:32 pm

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


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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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