April 1, 2008 at 9:35 am

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

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

Picking up a line

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

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

Following it along

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

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

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

Crossing it with others

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

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

Time, reconfigured by poetry, allows connection.

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

Stretching further

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

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

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

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



Writing And Medicine: Making It Up As You Go Along

February 26, 2008 at 10:21 am

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

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

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

Putting It Into Words

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

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

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

Telling Stories About Telling Stories

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

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

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

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

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

A Psychiatrist and a Poet

December 8, 2007 at 5:42 pm

Brain and Perception

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

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

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

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

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

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

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

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

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

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

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

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

Grey Land: Soldiers on War

November 22, 2007 at 3:53 pm


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

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

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

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

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

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

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

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

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

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

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

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

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

Toward a New Aesthetic of the Body

October 21, 2007 at 6:34 pm

Stretching Figure with Vertebral Scoliosis

Commentary by Laura Ferguson, Artist working in New York City

Can a deformed body be beautiful? Yes, through an artist's eyes - and I believe art can help medicine to broaden its vision, and embrace a new aesthetic of the body.

I'm an artist and for the past twenty years I've been using my own body, inside and out, as the subject of my work. My anatomy is an unusual one because of scoliosis, a curvature of the spine, and I found intriguing visual possibilities in the image of a body that was beautiful yet flawed. My drawings are quite intimate and personal, and at the same time strongly based on science, on an understanding of anatomy and physiology, and specifically on medical images of my own skeleton that were made for this purpose.

To help me deal with pain and physical frailty, I turned to movement practices like yoga, Alexander Technique, and neuromuscular training. I learned how to compensate for muscle and joint imbalances and make subtle postural adjustments. I came to know and feel my body from the inside out, becoming more sensitive to its proprioceptive, inner body sensors and signals. I felt more symmetrical, whole, centered, and three-dimensional in my physical being - and better able to convey that sense of myself through the images I made.

I came to understand scoliosis as having a complex rotational dynamic, arising out of a growth process, albeit one that has gone awry. That allowed me to visualize my curving spine as a manifestation of flowing energy: in my drawings it's a graceful and sinuous shape that helps me to endow a still figure with movement.

The most powerful response to my work has come from people who have unusual anatomies themselves, and have never before seen such bodies portrayed as beautiful. I'll let a few of these viewers speak in their own moving and eloquent words:

I have to tell you how deeply exciting and beautiful I find your work. My right arm and leg were amputated two years ago, and I'm just now developing a friendly relationship with my body. You have helped me feel beautiful.

Your pictures have helped me to become more accepting of my body… Your drawings reflect a very whole person, not just a body. The figure is lovely, expressive, open and explorative…. This has had a greater impact than my friends trying to convince me that I can be crooked and desireable both! Well, your work proves that.

Somewhat to my surprise, many doctors and medical professionals also respond strongly to this work. It gives them insights into what it feels like to inhabit such a body, they tell me, and allows them to see beyond the deformed spine to the beauty, humanity, and individuality of the person. Still, almost all the orthopedists who tell me they love my work also try to convince me I should have more surgery - whether or not I've asked them for medical advice. Ultimately, it seems they can't help but see an unusual anatomy as a problem to be fixed.

As an artist, I understand that fixing, healing, transforming an abnormal body into a more normal one, is what gives doctors satisfaction, a sense of accomplishment - that it is their form of creative expression. But the result is that there is no alternative paradigm offered to patients, no acknowledgment that an unusual body might be okay the way it is - that there doesn't have to be a 'fix.'

I realize that the idea of deformity having its own beauty, without the need of fixing or altering, is a radical one. But I believe in an alternative vision of aesthetics in medicine, one that gives more value to process, to empathetic connection, than to fixing or curing. Art is a good place to look for an alternative aesthetic: a place where the less-than-perfect body can be shown to have its own kind of beauty, grace, sensuality, originality.