Lincoln in the Bardo in the Bardo/ by Russell Teagarden

April 5, 2017 at 11:36 am

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

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

I.

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

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

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

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

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

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

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

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

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

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

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

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

 

 

II.

 

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

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

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

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

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

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

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

 

III.

 

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

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

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

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

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

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

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

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

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

 

IV.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

…………………………………………

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

 

The Knick by Gregory Clark

February 22, 2017 at 10:17 am

"The More Things Change, The More They Stay The Same"

When I first watched The Knick two years ago, it seemed like a show about the past and the rapid pace of medical discoveries in the early days of modern medicine, before antibiotics, when patients were still brought into the hospital on an ambulance pulled by horses. When I watched the fictional Dr. Thackery using electricity for the first time in his operating room, I couldn't help but sit back smugly and marvel at how far we have come since those early days of modern medicine.

Now, re-watching the first season of The Knick as a first year medical student in NYC, I've found myself focusing more on the similarities between medicine at the turn of the 20th century and today than the differences. Part of my excitement is particular to being in NYC. I get a thrill when I recognize street names, or when they mention the hospitals where I am slowly learning how to be a doctor. In a deeper way though, I no longer see the characters in The Knick as distant, historical figures. The problems that they confront are many of the problems we face in our medical culture today: the pervasiveness of racism; the stigma surrounding mental health issues; birth control rights for women; doctors becoming addicted to their own drugs; and even how to pay for the treatment of uninsured patients.

Now when I watch The Knick, I wonder how could it be possible that we are no closer to solving these problems a full century later.

The same racism and disrespect that Dr. Algernon Edwards faces as a black doctor is still present today. Minorities are underrepresented as doctors, and underserved as patients. For example, a study from researchers at the University of Pennsylvania found that African Americans were 34% less likely to be prescribed opioid pain medication for common chronic pain problems than white counterparts with similar problems. Similarly, when Dr. Thackery becomes addicted to cocaine, a drug used as an anesthetic at the turn of the 20th century, it is easy draw parallels to the opioid epidemic that our nation is currently facing.

One of the scenes that struck me most was the opening of the first show. It begins with the suicide of a surgeon after a failed operation. Since entering medical school, I have heard about physician and medical student suicide. Medical training is extremely challenging and stressful. Doctors are no less susceptible to depression than anyone else, even though it sometimes feels like people think they are invincible. Thankfully, these days, many institutions are striving to provide as much support as possible for physicians and students struggling with anxiety and depression. It was no accident that the writers of The Knick chose to begin their show with a scene addressing this.

Of course, we have made a tremendous amount of progress in medicine and society since the time of The Knick. I would never claim that medicine is the same today as it was a century ago. The most obvious plot points in the show demonstrate a stark contrast to our modern healthcare system. Yet, as someone within the medical community, I see The Knick as a call to arms. Medicine has come a long way, but many of the issues in the show are still extremely relevant today. The story of The Knick is not a story of medical history but a story of medical progress, and there is always room to move forward.

Gregory Clark is a member of the NYU School of Medicine Class of 2020.

 


Links to some of the studies I mention:

Time to Take Stock: A Meta-Analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States
>>Read here

Depressive symptoms in medical students and residents: a multi-school study
>>Read here

Link to the an annotation by J. Russell Teagarden in the The Literature, Arts and Medicine Database (LitMed)
>> Read here

 

 

 

Posthumous Portraiture Exhibit at the Folk Art Museum

January 27, 2017 at 3:11 pm

By Gabriel Redel-Traub

There is something eerie about walking into the Folk Art Museum's posthumous portraiture exhibit. The last line of the introductory panel to the exhibit reads: "We cannot help but hear them whisper 'remember me.'" This sentiment rings true.

Baby in Blue by William Matthew *

The exhibit is split into three rooms and filled with portraits of apparently posthumous subjects. I say apparently, because to a 21st century viewer, nothing in these portraits would indicate that the subjects were dead at the time they were painted. Informative panels, however, inform us that there are visual clues, motifs, and allusions in each portrait which would suggest to a 19th century viewer that the subject had passed away prior to the portrait being painted. This explains why many of the portraits have subjects with only one shoe on and why there are cats in many of the pieces.

The large majority of the pieces on display in the exhibit are simple portraits. The onlooker is directly confronted by the subject. In this way, these folk-art portraits differ drastically from the canonical depictions of death in the works of our greatest artists. In these works, death is taken as an opportunity to grapple with life, futility and grief: Michaelangelo's Pieta and Edvard Munch's By the Deathbed come to mind.

 

Edvard Munch's By the Deathbed

The simple mimetic nature of these folk-art portraits, on the other hand, is in part explained by their purpose. Many of the portraits on display in the exhibit were originally meant to hang in the home of the family of the deceased, a visual representation of a lost loved one serving the purpose a photo would today. As such, the portraits show their subjects as what they are not, vivacious: children play with dolls, a young girl picks flowers, a young boy fishes in a lake.

In stark contrast to the paintings' vivacity, the exhibit also includes 80 daguerreotypes with haunting black and white images of dead adults, or parents with bleak expressions staring out at you, their dead children strewn across their laps. The images arranged together in a small room of the exhibit force the viewer into a direct confrontation with the dead and are particularly haunting.

And yet, still, even though most of the portraits don't show explicitly posthumous subjects, there remains an eerie feeling throughout the exhibit.ASome part of that strangeness can be explained by the fact that the artists of many of the pieces in the exhibit were untrained giving their work a medieval feel- namely, the tendency to paint strangely adult faces on young children

However, the greater contributing factor, I think, is the mere knowledge that each portrait- and most of the portraits are of children- was made posthumously. This forces uncomfortable questions: was the deceased arranged as a model to be painted from? Or was the subject drawn from memory? How exactly did this process work? The information provided by the museum only partially answers these questions.

The Farwell Children by Deacon Robert Peckham *

The exhibit forces the modern onlooker into an empathic interaction with the deceased and with the story that the onlooker creates. In one particularly haunting piece The Farwell Children, five children look on demanding you take them in. Did all five of these young children die? Where did they come from? Where are the mother and father and how could they possibly endure this? The exhibit thrusts us into a more intimate conversation with death; one which our ancestors- for whom death was constantly looming more ominously over- were often preemptively forced into.

In the 21st century, the overwhelming attitude towards death is to push it away-out of sight, out of mind. This is, frighteningly, true for medical professionals and students studying medicine. The D word is taboo, everything a doctor is fighting against, so why should it even be brought up? And yet, death is also an invariable part of a medical student's experience. As Laura Ferguson, artist-in-residence at NYU School of Medicine writes:

 

"For most medical students today, the dissection of a cadaver represents their first confrontation with death, and with the visceral reality of the human body. They come to the experience with great curiosity but also with a degree of discomfort, even fear, about what they may encounter. They bring a sense of empathy and caring to their relationships with these "first patients" - but because it requires cutting, this rite of passage is their first experience of having to "hurt to heal." So, for many students, their time in the Anatomy Lab begins a process of emotional detachment."

Looking at the posthumous portraits- and at art more generally- serves as a way to reconnect, to reestablish the humanity and individuality of the deceased. It obliges us to find beauty in death and to acknowledge that death is an intimate part of life.

Securing the Shadow: Posthumous Portraiture in America is on at the American Folk Art Museum through February 26th A

Gabriel Redel-Traub is a 1st year medical student at NYU School of Medicine and a Rudin Fellow for 2016-2017.

* The Farwell Children Deacon Robert Peckham (1785-1877)
Fitchburg, Massachusetts c. 1841
Oil on canvas 53 1/2 x 40 1/2″; 62 1/2 x 48″ (framed)
Collection American Folk Art Museum, New York
Gift of Ralph Esmerian, 2005.8.11
Photo © 2000 John Bigelow Taylor

* Baby in Blue William Matthew Prior (1806-1873)
New England c. 1845 Oil on paper on wood 23 3/4 x 17″; 29 3/8 x 22 5/8 x 1 1/4″ (framed)
Collection National Gallery of Art, Washington Gift of Edgar William and Bernice Chrysler Garbisch, 1953.5.58 Photo courtesy National Gallery of Art, Washington

States of Grace: From Doctor to Patient and Back Again

April 5, 2016 at 3:39 pm

Katie Grogan, DMH, MA and Tamara Prevatt, MA,
Master Scholars Program in Humanistic Medicine, NYU School of Medicine

 

facebook_SoG_poster
Before the accident, Dr. Grace Dammann was a caregiver through and through, in every aspect of her life. A pioneering AIDS specialist, she co-founded one of the first HIV/AIDS clinics for socioeconomically disadvantaged patients in San Francisco at Laguna Honda Hospital. She was honored by the Dalai Lama with an Unsung Heroes of Compassion Award for her service and devotion to this population. Grace was also the primary breadwinner and parent in her family with partner Nancy "Fu" Schroeder and adopted daughter Sabrina, who was born with cerebral palsy and HIV. She lived and worked in such close proximity to illness, death, and disability, but nothing could have prepared her for the devastating injuries she sustained when a driver veered across the divide on the Golden Gate Bridge, crashing head on into her car.

Grace spent seven weeks in a coma, hovering on the precipice between life and death, like so many of her own patients. Ultimately, she awoke with her cognitive abilities miraculously intact, but her body was irreversibly impaired, leaving her wheelchair-bound and dependent on others for simple daily tasks. States of Grace, a documentary film about her profound transformation, picks up Grace's story when she is discharged following a thirteen-month stay in rehabilitative hospitals. Members of NYU Langone Medical Center, including medical and nursing students as well as faculty and staff across all disciplines, were invited to attend a screening of the film and talkback with Dr. Grace Dammann and the filmmakers, Mark Lipman and Helen S. Cohen of Open Studio Productions.

States of Grace captures the expansive and rippling effects of the accident, how it left every corner of Grace's life radically altered-personal, professional, psychological, spiritual, and economic. The family dynamic is turned on its head. Fu becomes the primary caregiver to both Grace and Sabrina, and as Grace says, "Sabrina's position in the family was radically upgraded by the accident. She is so much more able-bodied than I am." Fu struggles with the enormity of the role she has signed up for. Grace wrestles with her gratitude for having survived and the frustrations of her new life: "I feel like I've lost a best friend-my body . . . When I first woke up, I was just glad to be alive, plain and simple. Now I'm just annoyed-annoyed at the limitations. I'm bored." In one scene we see Grace argue with Fu about her right to die if she continues to be so impaired.

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Grace grieves for her old life, for how effortless things were. We watch as her fierce resilience pulls her through to acceptance. She credits her Zen Buddhist practice for her ability to keep moving forward: "Nothing lasts forever, even great pain and sorrow." Though some of her ultimate goals-to walk again, to dance again, to surf again-remain unattainable at the film's conclusion, Grace sets, meets, and exceeds new ones. Acknowledging that she only felt completely whole when practicing medicine, she "comes out" as a disabled person to the medical community, returning to Laguna Honda Hospital as its first wheelchair-bound physician, where she is appointed Medical Director of the Pain Clinic. She resumes the caregiver role, but with an intimate knowledge of the lived experience of pain, suffering, and disability. In the talkback Grace remarked, "Once you disrupt the integrity of the body, you're disrupting the integrity of the psyche, and I don't think any of us think about that. I certainly didn't as a physician. I hate to admit how many times I discharged people without even getting them up to see that they could walk." She also brings her Buddhist training to the clinic, where she promotes wellness among the staff and patients by teaching meditation.

As the talkback ended, attendees lingered, eager to chat with the filmmakers and shake hands with Grace, awestruck by her story of triumph, adaptability, service, and the lessons learned on both sides of the doctor-patient divide.

Sabrina will graduate this May with her Bachelor's degree. Grace partnered with the driver who hit her to advocate for a median barrier on the Golden Gate Bridge to prevent similar accidents from happening in the future. The barrier was installed in January 2015.

This screening was co-sponsored by the Master Scholars Program in Humanistic Medicine, the Office of Medical Education, and the Department of Physical Medicine and Rehabilitation. Special thanks to Drs. Pamela Rosenthal and Marianne Sommerville for bringing the film to NYULMC. For more information on States of Grace and to arrange a screening, go to: www.statesofgracefilm.com

 

Cortney Davis - When the Nurse Becomes a Patient: A Story in Words and Images

March 23, 2016 at 1:17 pm

CortneyDavis_blog

NYU Langone Medical Center welcomed author/painter Cortney Davis to the Smilow gallery for the opening of "When the Nurse Becomes a Patient." Laura Ferguson's interview with Ms. Davis appears here.

Exhibition presented at the NYU Langone Medical Center Art Gallery by the Art Program and Collection.
Photo: Art Program and Collection.

 

Drawing the Human Heart

January 29, 2016 at 11:33 am

This video is adapted from a presentation delivered by our Art Editor, Laura Ferguson, at the 2015 conference of the American Society for Bioethics + Humanities.

In the video, Laura talks about her journey as an artist, the many years she spent exploring her own anatomy and finding beauty in a curving spine - and how it brought her to the the Anatomy Lab at NYU’s School of Medicine as Artist in Residence. There, she uses the expressive power of art to help medical students stay engaged in the emotionally complicated task of dissecting a human body.

links to "How To Draw a Human Heart," a short film about Laura and her Art & Anatomy class, directed by Emon Hassan:
www.lauraferguson.net/art-medicine/
narrative.ly/art-in-strange-places/how-to-draw-a-human-heart/

Medical Photography Exposed- Part 2

September 18, 2015 at 1:24 pm

In Part 2 of her interview with Katie Grogan, Emily Milam discusses how photography is used in medicine today. For Part I, click here.

 
As a second component to your project, you surveyed dermatologists nationwide about their use and opinion of medical photography. What did you discover about current practices?

Current practices vary depending on the clinical setting and the specialty. I restricted my survey to dermatologists because it is a population that relies on regular use of medical photography. I also chose this group because I do clinical dermatology research, so I have greater access to that population. But plastic surgery and other subspecialties that are particularly visually-oriented also rely on medical photography. To be honest, most fields use medical photography or images in some capacity, whether it's CT scans, MRIs, endoscopic images during a colonoscopy, intraoperative images of a patient's abdomen - these are all forms of photography to some extent.

The goal of the study is to better characterize the use of medical photography, including issues of technology, image storage, consent, and patient privacy. Despite its ubiquitous use, little is known about how photography is employed in the clinical setting.

Is there any formal training for medical professionals to encourage universal responsible photography practices?

To my knowledge, there are very few formal training opportunities. There are courses at national meetings, and some residency programs teach basic photography skills. There are also a handful of review articles in academic journals and CME courses that guide readers on how to focus a camera and things to keep in mind while taking photographs. Some medical centers are fortunate enough to have a professional medical photographer on hand who can take that expertise and apply it to patients throughout the hospital instead of having to rely on physicians. Also, with the advent of telemedicine, there is a focus on training physicians to be skillful photographers so that the images are clear and accurate representations of the disease that they are trying to transmit. I think there is still room for improvement. Medical photography tutorials should be a required component of training for many specialties, especially within the visually-oriented fields such as dermatology and plastic surgery. Beyond teaching students how to use digital cameras and take images that are in focus and with adequate light, it is also important to teach them how to drape a patient properly, what should and should not be included in the image, to remember to remove identifying jewelry and to cover tattoos and avoid the face if it is not the subject of the photo. I think that this is a benefit to everyone because oftentimes you can't publish photos that don't meet those criteria anyway. Other important tips are to place a ruler next to the lesion of interest for scale or to take follow up images at similar distances and angles so that they are more comparable. You'd be surprised how few photographs fulfill these criteria, including images published in some of the best academic journals.

Today, when a medical photograph does feature a patient's face, are there steps taken to protect that person's identity?

That's changed in recent years. At the end of the 20th century - the 70s, 80s, 90s - it was very common to put a black bar over the patient's eyes after the picture had been taken, using a computer to pixelate the image, or some other post hoc editing changes. It was later determined to be kind of silly - you can still tell who's who in a photograph with the eyes covered. So the focus now is on gaining consent, making sure the patient is informed about how their photograph is being used, doing the necessary paperwork, and if the area of interest is the face, including the face - eyes and all. There is greater emphasis placed on making sure the patient is fully aware and on board with how their photos are being used.

Medical photography can really come to bear on patient-physician trust then, right? How do you think it shapes this relationship?

I think that the relationship between patient and physician can go either way. In the modern age of technology, in some sense, patients expect their photographs to be taken, especially if it's for a procedure where they're looking to have before and after differences, or tracking their disease over time. But in the end, to maintain trust, it's important for the physician to fully communicate what they intend to do with the photograph, why they need it, and where it's going to be stored. Otherwise patients may be skeptical or distrustful, and it might make them nervous to come back. There is actually a study by dermatologists at Bellevue and NYULMC clinics, where patients were surveyed on their perspective of medical photography. In that survey, a majority of patients agreed that photography enhanced their quality of care, and they were okay with it. And they were okay with their photograph being used for medical purposes, for their continuity of care, teaching and research purposes, but particularly when the photographs were not identifiable. The study also found that patients preferred the use of clinic-owned cameras above personal cameras or smartphones. They preferred physicians to take the photos and not nurses or medical students. While patients are open to medical photography, there are some things that we need to be mindful of to make it comfortable and to continue that trust and even empower that relationship.

What do you think patients should be aware of when they are asked to be photographed?

I think they should know what their images are being used for, whether that's education, publications, part of their historical medical chart, or medico-legal purposes. This communication should be part of the informed consent process prior to taking the photograph. But obviously in the rushed world of clinical medicine this doesn't always happen. I think if patients understood that their photographs are a benefit to their clinical care as well as a useful instructional tool to trainees and journal audiences, they would feel more comfortable with the process and perhaps even take pride in their involvement. In fact, I've written a few case reports as part of my medical research, and I've found that a couple of patients were very excited to be a part of a journal and to be helping in some way, even if it showed them with a strange rash.

And when a patient consents to have their photograph taken in a clinical context, what does that mean for ownership of the image? Whose property is it?

That's a good question. It is very hard to say because when a patient agrees to have their image published in a journal, it is very difficult to take it back down the road. So you can argue that a patient no longer has control of the image, especially on the Internet. Once it's on the Internet, it's very hard to extract.

As the third and final component of your project you examined creative portrait projects that feature individuals who have visible diseases aimed at reframing the way we see them. What is different about portrait photography and contemporary medical photography? Why do you think photography is such a powerful medium for raising our consciousness?

Creative portrait projects have provided patients the opportunity to be the subject of art and not just the subject of clinical attention in the medical gaze. It allows them to reclaim their appearance and feel special rather than peculiar. That can be very empowering. These projects are important not only because they empower the portrait subject but also because of their rippling effect in empowering others with similar disfiguring diseases who see the portraits and then can identify with the portrait subjects and say, "There are other people out there like me." It's also important for people who are not disfigured to see the diversity of appearances.

Outside of this project you enjoy photography and documenting your experiences through pictures. Does this inform the way that you see patients? Are you observing your surroundings through multiple lenses, from medical and artistic standpoints?

Absolutely. When I observe clinicians taking photographs of patients or when I'm tasked to do it myself in the medical office, I can't help but consider the principles of perspective and depth of field that I learned in college photography. I can't help but look at the subject and the surroundings as kind of artful in some way. But I also have to remember that medical photographs, when used in clinical medicine, are not intended to be artful. They are supposed to be accurate representations of disease that convey clinical truths. There are two different sides of the coin, and I'd like to think that my interest in photography helps medical photography. I'm able to bring images into clear focus and center the photograph and make sure they are standing appropriately and able to consider the aesthetic elements that are helpful for the clinical needs or the purpose of the photograph. But sometimes it's hard not to want to play around and do creative things.

I hear the distinction you're making, but I wonder if those two things can really be so separate - where a medical photograph is completely objective and doesn't involve the subjective elements of perspective and framing.

I totally agree and in the end you're photographing a human, so you're seeing a human - whether that's through an objective medical gaze or you're peering into what they might be going through because of the malady they have and the reason why they are being photographed. So I don't think they can be separated. I think they go hand-in-hand and are kind of a composite entity.

From this whole process, going through all the photos you studied, do you have a favorite image that really spoke to you and maybe captured the spirit of this project?

It's hard to pick one, but one of my favorites is a photo taken by the medical photographer at Bellevue that I mentioned, Oscar G. Mason. My Rudin fellowship mentor, Dr. Oshinsky, initially told me about the photograph and I think it perfectly encapsulates the purpose of my project, not to mention its historical link to NYU. This photo, nicknamed "The Bellevue Venus," shows a young woman with a debilitating case of elephantitis of the legs. It was published by George Henry Fox in his dermatology atlas, Photographic Illustrations of Skin Diseases in the 1880's. What is striking about this photo is the way the subject has a cloth draped over her head and is covering her exposed chest, perhaps out of modesty or shame, or to protect her privacy or anonymity, yet it is such a clear representation of disease at the same time. You can almost imagine the overlap of the physical and psychosocial distress in this one image.

Bellevue_Venus

"Bellevue Venus," photograph by Oscar G. Mason, The Bellevue Photographic Department

The fellowship year is about to end, and I understand that you have a few manuscripts in the works. What are you working on, and what do you imagine to be the future of this project?

I did have a paper accepted for publication, and it should be coming out in JAMA Dermatology in the next few months. It's a historical survey of the first dermatology atlases, after photography was invented. In this era, many of the photos were hand painted by artists to give color to the otherwise black and white images. I also discuss Oscar G. Mason and George Henry Fox's dermatology atlas. I'm working on a few other pieces for publication, including one on the psychosocial implications of one's appearance and society's "beauty biases." I'm also working on a manuscript that discusses, in depth, the legal cases that have shaped medical photography and the current guidelines we have today concerning consent and image security. Finally, I've also compiled a list of portrait projects that exist, showcasing different visible ailments such as alopecia, vitiligo, and craniofacial conditions. I want to have that on a site where people can find them and look through the images and feel empowered.

I want to take photographs of patients at some point. It's been interesting how some of the issues I've researched have been a barrier in my ability to take photographs of patients, such as concerns about image and privacy and anonymity. I still hope to have the opportunity to photograph patients and give them the chance to be the subject of art.

And, finally, you're planning to go into one of the visually-oriented fields of dermatology, so how do you imagine both your interest in photography and the knowledge you've gained from this project will shape the way you integrate photography into your practice?

Well, for one, I definitely hope that photography is a large part of my practice, and that means taking photographs of patients to track their disease progression or to use in educational materials. But I'm going to be very aware of the patient's experience in that process and make sure that I am clear and forward in what the photographs are going to be used for and provide patients the opportunity to opt out. I also want to help create educational tools or teach my future colleagues how to take photographs correctly. I see that on the horizon. Once I'm a physician, I will have built relationships with my patients and may have an easier time taking photographs of them - both clinical and creative - and they won't just come to me for their medical illness.

Medical Photography Exposed - Part I

September 9, 2015 at 12:44 pm

An Interview with Emily Milam, MS4, NYU School of Medicine, Rudin Fellow 2014-15

By: Katie Grogan, DMH, Associate Director, Master Scholars Program in Humanistic Medicine, NYU School of Medicine

The Rudin Fellowship in Medical Ethics and Humanities supports medical trainees at NYU School of Medicine - including medical students, residents, and clinical fellows - pursuing year-long research projects in medical humanities and medical ethics under the mentorship of senior faculty. It was established in 2014 through a grant from the Louis and Rachel Rudin Foundation, Inc and is a core component of the Master Scholars Program in Humanistic Medicine.

Emily_Milam

Emily receiving her fellowship certificate from Drs. David Oshinsky, her Rudin Mentor, and Lynn Buckvar-Keltz, Associate Dean for Student Affairs, at the Rudin Fellowship Project Showcase, July 7, 2015

How did you become interested in medical photography and why did you decide to develop this into a research project as part of the Rudin Fellowship?

My interest in medical photography stems from a longstanding appreciation of portrait photography, since the two overlap so much. I first took a portrait photography class in college. In medicine, much of our education relies on illustrations from photographs. So when we aren't learning from the patients themselves in clinical rotations, we're learning from textbooks and the Internet where we see photos of patients with these diseases. I've always wondered what the experience was like for the patient who is photographed. What were they feeling? What did they think would become of that photograph? Did they know it would be in textbooks for thousands of people to see years later? I imagine that the experience would be perhaps embarrassing for some but fulfilling for others. I wanted to explore the different emotions and scenarios in which portrait photographs were taken in medicine.

One component of the project was a historical survey of medical photography. I imagine that most people, whether they are in healthcare or not, know very little about the origins of medical photography. When and how did it become integrated in medical practice?

Photography in some form has been around for centuries, starting with principles of the camera obscura. But the birth of photography is often credited to Louis Daguerre, who developed the daguerreotype process - the first photographic image with permanence - in the 1830s. After that it's thought that the first application of photography to medicine was in the 1840s, when a physician named Alfred Donne published a cytology atlas of 86 daguerreotypes of micrographic images in his book Cours de Microscopie with the help of a photographer named Leon Foucault. The earliest medical portrait is an 1847 photograph depicting a woman with a sizeable goiter, taken by two Scottish photographers, David Octavius Hill and Robert Adamson. There are many other examples of medical portraiture in the years thereafter, including the earliest known dermatologic daguerreotype of a burn victim's distorted face and neck published by a surgeon in Philadelphia's Medical Examiner. There was also a psychiatrist, Dr. Hugh Welch Diamond, who gathered a collection of psychiatric portraits of asylum patients, which he used for diagnostic purposes and case reports, but he also showed them to the patients after their treatment had finished to say, "See: this is the state you were in prior to coming to me." Finally, I'll just mention, the first medical photography department in the United States was at Bellevue, under the guidance of photographer Oscar G. Mason. He encouraged physicians to use photographs to describe landmark cases, surgical cases, and medical cases. He also helped physicians compile photographs for atlases of disease, and those can be viewed to this day.

Portrait and medical photography seem so distinct from one another. One emphasizes the wholeness and personhood of the subject, while the other captures a specific body part or condition of interest. It's interesting that early medical photography employed portraiture so heavily. Was the implementation of medical photography in the 19th century about documenting the patient experiences or advancing scientific knowledge?

I think it was a blend of the two. The purpose was definitely to advance scientific knowledge and to show these diseases, and to be able to send these photographs to other physicians around the country or world so that they could learn from unique cases. That couldn't really be done until the photographic technology allowed for prints to be lighter, smaller, and easier to transport. But when you look at early photographs of the late 19th century, you see very staged poses, with the use of props and backdrops, and they look like formal portrait photographs. So, there was a time when the two really overlapped, as medical photography was gaining its foothold and becoming more of a scientific endeavor and less about artful portraiture.

I know you combed through some really fascinating archives. What types of images did you find? What surprised you most about what you saw?

I scoured many places, especially the Internet, because there are so many archival photographs available, but there is nothing like holding an old tattered photograph or a reflective daguerreotype - they almost look like mirrors, and they are really special to see. I was able to travel to the Morbid Anatomy Museum in Brooklyn and also the Mutter Museum in Philadelphia. I spent the day sorting through original medical photographs from the late 19th and early 20th centuries, particularly photographs of Civil War veterans who had an array of amputations and maladies related to their time in the war. What's so striking is how formal some of the photographs are. A lot of the subjects are dressed very elegantly - with their top hats, bowties, and ruffled shirts - and they're posing formally, taking a sort of pride in their image and perhaps even their malady, though I can only speculate. I was also surprised, on the other side, to see portraits that seemed to portray patients' embarrassment or modesty about their illness, whether communicated by a look you can see in their eyes or their decision to cover their faces. Again, I can only speculate why they were covered - maybe it was the photographer's choice or the physician's or the patient's, it's hard to know for sure.

In our modern medical landscape, patient autonomy is paramount. When we talk about medical photography, what immediately comes to mind for me are issues of consent and privacy. Were these concerns for early medical photographers? How did this change over time?

In the present day, patient privacy, image security, and image quality are definitely paramount. I think early medical photographers were also concerned with image quality, but they employed the techniques of traditional portrait photography to showcase the high quality of their medical photographs, with the props, clothing, and elaborate backdrops. But underlying class issues and race issues came into play as well. There are photos that show patients of different races with similar conditionsaa leg amputation, for example - but the black patient is naked and the white upper-class patient is elegantly dressed and wearing full attire. In general, I think patient privacy was less of a concern. You can even find photographs with patients holding up signs with their names and other identifying information.

G. Porubsky

G. Porubsky, Co B. 46th NY volunteer, photograph by R.B. Bontecou, from Shooting Soldiers: Civil War Medical Photography, by Stanley Burns, MD, published by Burns Archive

Was there one landmark legal case that really altered the course of medical photography with regards to privacy?

It's hard to pinpoint one case that changed the medical photography landscape but one of the first landmark privacy cases that hinged on photography was Roberson v. Rochester Folding Box Company in 1902. Basically, in this case the Franklin Mills Flower Company had hired Rochester Folding Box to print 25,000 advertisement posters. On these posters was the face of a young girl named Abigail Roberson, a teenager whose portrait had been taken at a photography studio for personal use. She never consented to its public display. Unbeknownst to her, the photos were placed all around town, and she learned of them through friends and family who recognized her. She reported experiencing "great distress and suffering in both body and mind" and she had a nervous breakdown, essentially, because of the embarrassment. While the judge ruled in favor of Rochester Folding Box, her case led to really rampant discussion about privacy and whether or not you own your own image. Over time, a decision related to this case ruled that, in fact, you do own your own image and the rights to decide what can be done with it. There are so many other interesting cases. One is Claymann v. Bernstein in 1940, in which the court ruled that a physician could not use a photograph of a patient's facial development for the purpose of medical instruction without consent. So even if it was just to be shared between medical students and residents, if consent had not been acquired, then it was not allowed. In a 1961 case in Louisiana, McAndrews v. Roy, a patient sued for an invasion of privacy after a physician published an image ten years after the patient consented. The judge found it unreasonable to publish photos after so much time had elapsed. So the rules we know today stem from several legal cases over time.

The gold standard today is really written consent, right? In these cases, what was the method of consent?

For the case of the elapsed time, I think it was a written consent. But even today not all institutions do written consentathey'll do verbal and document in the chart, "consent gained verbally," and some people don't do consent at all. So, it's definitely a fine line still, despite all of these cases.

To be continued

Visualizing Empathy: An interview with Laura Ferguson

April 14, 2014 at 12:40 pm

Artist Laura Ferguson developed a lifelong passion for drawing the body, both inside and out, as a child when she was bedridden with scoliosis. Five years ago she created an Art and Anatomy seminar in the Masters Scholars program, as part of an artist residency at NYU SOM.

The class, which includes medical students, faculty and staff, meets in the cadaver lab where gross anatomy is taught. Once transposed into an art studio, the setting provides students with a chance to engage with the dissection experience more creatively than in gross anatomy, where the focus is on learning the parts of the body and what happens during the disease process. The simple act of drawing, Ms. Ferguson says, encourages a more intimate involvement with the beauty, complexity, mortality, and visceral reality of the human body.

"These artists are imagining the living body as they draw: looking at bones and cadavers but imagining the person who once inhabited them - and also imagining the living, moving anatomy within themselves."
"There is an inherent humanism in art, and a great power to communicate - to express things that can't be as easily communicated in other ways. Art allows us to share experiences that go deep into the human spirit and psyche - the same places where illness or pain or differentness or isolation often take us."

Ms. Ferguson brings her experience as a patient into the studio to encourage students to explore individual differences among body types. While she recognizes that students need to memorize organs, tissues, and nerves in order to become competent physicians, she stresses the importance of recognizing that variations in body types do not define the person nor the illness they may have at any given time.

This year, Ms. Ferguson organized an exhibit of "Art & Anatomy: Drawings" in the MSB Gallery at NYU Langone Medical Center, featuring 76 artworks made in the class. Ms. Ferguson said she was struck by the audience's powerful reaction to the exhibit-for some there was an inherent discomfort, even fear, connected with seeing the inner body, but that became a shared sense of wonder for the viewers as they recognized the transformation of anatomy into art.

At the opening of the exhibit, Hannah Bernstein, one of the student artists, had this to say:

"When I created drawings for the course I tried to capture this appreciation for the beauty and variation of the human body. I learned to appreciate things that aren't conventionally beautiful, like the curves of the femur and the intricate network of blood vessels covering the heart. I also learned that in general, real people don't look like textbook illustrations. No two people are the same, and no one is 'perfect.' Each body has its own unique deviations, and this applies to what's inside as much as what's on the surface. This is an important lesson for any future doctor, and I'm grateful that I got to learn it from such a unique perspective."

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More on Art and Anatomy

•On April 30th, a slideshow of "Art & Anatomy: Drawings" will be screened as part of "Reading the Body: Live!"! - a literary evening honoring Frank Netter, with stage actors reading poetry and prose about the body from the Bellevue Literary Review.
•A gallery of images from the show can be viewed online at http://school.med.nyu.edu/humanisticmed.
•A short film about Laura Ferguson and Art & Anatomy was recently featured as one of its "untold stories" by Narrative,ly (http://narrative.ly/art-in-strange-places/how-to-draw-a-human-heart/).

The Artist in the Anatomy Lab

June 26, 2012 at 3:16 pm

Laura Ferguson came to the NYU School of Medicine as artist in residence in 2008 and currently has an exhibit of her artwork in the MSB Gallery at NYU - Langone. In a previous blog post, Ms. Ferguson discussed how she uses medical imagery in her work. In speaking with her by phone in the days following the opening of the current exhibit, I asked her to discuss her work with medical students who study anatomical drawing with her during an eight session elective, 'Art & Anatomy,' in NYU's Master Scholars Medical Humanism Program.

In her work with students (as well as faculty and staff) Ms. Ferguson sees herself as a mediator between the world of art and medicine and between doctors and patients. Excerpted below is some of our conversation.

-Lucy Bruell, Editor-in-Chief, Literature, Arts, and Medicine Database

I came to NYUSOM with the idea that an artist’s perspective could be of value to the medical school community. This exhibit is a chance for me to show what I’ve been doing as an artist in the four years that I’ve been here. I've learned so much in my interactions with faculty, staff, and students. This is a chance for me to give back and to share what I’ve been doing, which was part of my original goal. My work with students has been a big part of that.

When I first came in, the first year, the students would study gross anatomy the first semester of medical school, and those who wanted to took my class in the spring semester. In other words, they’d have dissection in the fall, and then drawing in the spring. But after that, the curriculum started changing, and now they have gross anatomy spaced out over 18 months. And they may take my class whenever they want to, because it’s given every spring and fall semester, so they may be at different stages in learning anatomy. Some of them may even take my class before starting gross anatomy, so I become the person who introduces them to the lab, which I wasn’t expecting. But I've always thought that drawing is a great way to learn.

I basically learned anatomy through drawing. You spend so much time communing with the object or the thing that you’re drawing that you come to know it in a way that’s much deeper than dissecting it or just looking at it in a book. It’s a very different relationship to being with the cadaver, or the bone. Drawing in the anatomy lab is much more open ended; it’s just about the process of learning and drawing. You don’t have to memorize anything, or have a test afterwards, so it’s very relaxed, freer. There’s also a mindfulness that you get into when you’re drawing, that I thought would also be a good experience for doctors-to-be, just to have a different connection to the bodies. Another aspect is the idea of individuality, which is an important part of gross anatomy. The fact that there are all these different cadavers, all these different people, and each one is different from the others. The students get to look at different ones and see all these anomalous things. But when they’re looking at the anomalous things, it’s largely to see pathologies, or things that are wrong. Obviously they need to learn that sort of stuff, but my approach, especially as someone with scoliosis, is more to just appreciate the individuality; that we’re all different inside, just as we’re all different on the outside.

The class is held in the anatomy lab. When you enter, there’s a study room in the middle, with just tables. You don’t see any cadavers when you first look in. And then on the two sides there are two rooms that have all the cadavers. We first meet in that middle room, and I start them off with drawing bones. Next, I give them a tour of the cadavers, especially for the ones that haven’t been in the lab before, and when they’re ready, I let them start drawing in there. Sometimes we actually take out a heart or a lung from the cadavers on a tray, and they draw it. It can be a little tricky, because we have to depend on what stage the students are at in dissecting: when they've just begun, there's not much to look at or draw, and when they're almost done, the cadavers may be hard to look at. But we manage to find something to draw at all these different stages.



In the beginning, I tried to get the students to talk about the emotional side of being in the anatomy lab. Some did, but others were resistant, and would just say "We’re fine. After the first day we got used to it." Which is probably true on one level, but on another level, there has to be a lot going on - it’s such a profound experience. But when you’re drawing, you’re expressing yourself, whether you like it or not. Something’s coming out of you - especially if you’re drawing from a cadaver or a part of one. You’re bound to be, on some level, dealing with feelings. To let it happen, in an open, non-judgmental environment, has an effect. And students do talk to me at different times about the deeper issues of being in the anatomy lab, how they deal with that in different ways…

The biggest problem for students is time, so the class is a treasured thing. They can’t always make it to every session. But the ones who do come, I think it means a lot to them. I’ve been very amazed and interested to find how many of the students actually have some sort of arts background, or humanities background, and for them it’s a link to a whole other side of themselves that they may feel they have to put aside in medical school. So it can be very meaningful - their drawings are something they can show to their friends and family- they can make that connection to the other side of their interests that they had before they started medical school.

Laura Ferguson's exhibit will be on display until August 13th. An exhibit of student work is scheduled for November.