Sherman Alexie Wins PEN/Faulkner Award

March 24, 2010 at 11:18 am

I’d like to call attention to yesterday’s announcement of the 2010 PEN/Faulkner Award for fiction, Author Sherman Alexie is the winner for fiction (War Dances, annotated in the Literature, Arts, and Medicine Database) and if you haven’t read any of his work you are missing a treat. He is a prolific author of essays, fiction, poetry, and also wrote three screenplays. Figuring in much of his work are his experiences as a Coeur d’Alene/Spokane Indian who lived on the "rez" interfacing with "white" society and who continues to span these borders off the reservation. His style and point of view are unique — humorous, perceptive, original, pointed, poignant. Coincidentally, I had just finished annotating and posting the film, Smoke Signals, for which Alexie wrote the screenplay, when I learned that he was the recipient of this award. Every time I watch that film I find something new to savor so I was particularly pleased to learn of this award.

Felice Aull

The "Parallel 'Parallel Chart'"

March 8, 2010 at 5:58 pm

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

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

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

Interactive Reflective Writing

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

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

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

The Teacher's Experience

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

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

Concluding Reflections

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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


Rescuing Sympathy

November 30, 2009 at 2:24 pm

Female doctor talks to female patient

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

Many authors who write about empathy in medicine are careful to draw a bright line between sympathy and empathy. For example, Hojat in his excellent survey of research on Empathy in Patient Care, considers the two concepts as almost dichotomous, albeit with a small area of overlap. (1) In this categorization, empathy is a cognitive attribute that allows us to understand the selfhood of another person, or, as Hojat puts it, "the kind and quality of the patient's experiences." (1, p. 12) Alternatively, sympathy is an affective or emotional attribute that plays a somewhat ambiguous, if not detrimental, role in medical practice. The bottom line message is that experiencing too much sympathy for patients distorts the clinician's medical judgment, thus harming the patient; and at the same time causes the clinician to "absorb" too much suffering, thus leading to professional burn-out. Interestingly, these authors seem unconcerned about the question of too little sympathy. Presumably, they agree that clinicians ought to care for their patients, i.e. feel-for or have compassion. Therefore, they must believe that a modest amount of sympathy is essential for patient care, but they never discuss how to develop or maintain sympathy. Their main concern is that it not be confused with empathy.

Empathy

Empathy is a hard nut to crack because it challenges the conventional medical opinion that thinking is thinking and feeling is feeling and never the twain shall meet. Empathy is a process by which we try to understand other people's experience: how they feel, where they are coming from. To the extent that we accomplish this, we are considered empathic and should score highly on a reliable test of this quality. Thus, empathy is a cognitive process, but the content (the known) includes emotions. To "know" emotions we have to feel them. Jodi Halpern uses the term resonance emotions to describe these feelings generated in the clinician as she practices empathy. (2) She writes, "The special professional skill of clinical empathy is distinguished by the use of this subjective, experiential input for specific, cognitive aims. Empathy has as its goal imagining how it feels to be in another person’s situation." (3)

I speak of "practicing," rather than "having," empathy because I want to focus on the professional skill component, rather than the natural endowment (i.e. more or less hardwired) component. In Howard Spiro's famous essay "What is empathy and can it be taught?" he answers the second question with a qualified "yes." He writes that "a better question might be, 'Can we recover the empathy we once had?'" (4) Arguing that the process of medical education tends to diminish our openness to others' feelings and experience, Spiro believes that enhancing clinical empathy is more of a restoration project, rather than a pedagogical one. Perhaps he overstates the case, but it is clear that medical education tends to narrowly focus students' attention on patients-as-objects, thus down-regulating their receptors for experiencing patients-as-subjects. It can be argued that concepts like detachment, detached concern, and clinical distance describe an unfortunate situation that needs to be remedied, rather than a professional ideal.

Sympathy

What does this have to do with sympathy? I take sympathy to mean an emotional state in which we desire to "feel another person's emotions better" (Hojat's language, 1, p. 11). In clinical medicine this translates to "connect with" another person's suffering. In other words, to have sympathy for a patient is to have genuine care or compassion for that patient. Perhaps it is useful to warn students against submerging themselves in excessive sympathy, but I doubt it. After many years of observing medical students, residents, and senior physicians in practice, I don't believe that over-identification with patients is much of a problem. Some doctors seem not to connect with their patients as persons. In other words, patients don't engage much of a sympathetic response. I suspect these non-sympathetic doctors would also score poorly if they were subjected to an accurate test of clinical empathy. another group of doctors seem genuinely to care for their patients. They have a great deal of sympathy for patients. However, these clinicians appear to have the emotional resilience that allows them to experience sympathetic feelings, but also maintain a clinical perspective. I suspect these sympathizers would also score highly if they were subjected to an accurate test of clinical empathy.

Empathy and Sympathy

This brings me back to the original distinction between empathy and sympathy. I agree that a distinction exists, but I submit that the relationship is more complicated than most writers portray it. In many ways sympathy and empathy parallel one another: sympathetic clinicians tend to work harder at being empathic; unsympathetic doctors tend not to devote much effort to empathy. At the same time, empathy is clearly a cognitive process by which we may approximate an understanding of another's situation and feelings, while sympathy is an emotional state of affirming the other person while experiencing something of his or her suffering.

Concluding Thoughts

Let me conclude with the following observations:
1. Empathy precedes sympathy. I can't sympathize with a person unless I have some understanding of how he or she feels.
2. Sympathy feeds empathy. My feeling-for a person's suffering makes me more likely to engage that person empathically.
3. Clinicians are more likely to be compromised by having insufficient sympathy than by having excessive sympathy.
4. My use of the term "sympathy" may be somewhat at variance with the way Hojat and others define it. However, I believe that, insofar as the versions are different, my version corresponds better with common usage, while their version, in which sympathy is considered egoistic as opposed to altruistic (1), is somewhat confusing and perhaps a straw man.

References
1. Hojat M. Empathy in Patient Care. New York, Springer, 2009, pp. 10-15
2. Halpern J. Empathy: Using resonance emotions in the service of curiosity. In: Spiro H et al (Eds.) Empathy and the Practice of Medicine, New Haven, Yale University Press, 1992, pp. 160-73.
3. Halpern J. What is clinical empathy? J Gen Intern Med. 2003; 18: 670-674
4. Spiro H. What is empathy and can it be taught? In: Spiro H et al (Eds.) Empathy and the Practice of Medicine, New Haven, Yale University Press, 1992

 

Creating And Maintaining Participant Interest In The Medical Humanities

October 28, 2009 at 3:39 pm

Everest region: Living in harmony with nature. Photograph

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

In previous blog articles I looked at medical humanities teaching in Nepal, explored the link between trekking and the medical humanities in a Nepalese context, and discussed the benefits and disadvantages of English as the language of medical humanities teaching. In this article I will share my experiences of creating and maintaining interest in the medical humanities (MH) among student and faculty participants in two Nepalese medical schools.

The voluntary module at Pokhara

At the Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal a voluntary module was conducted for interested students and faculty members. (1, 2) Students from the third semester (basic sciences) and the fifth and sixth semester (clinical sciences) participated. Interested faculty members also joined the module.

Interest about the module was created through interactions at individual and group level with students and through posters and notices put up on the notice boards and prominent places on campus. (3) Students were invited to 'try out' the module for one or two sessions. If they found the module interesting they could continue- otherwise they could opt out.

Sessions for basic science students at Pokhara

The sessions for the third semester students were conducted during the afternoon lunch break. Each session was of 30 minutes duration. The number of students was small, not more than eight and they were highly motivated. Due to various problems sometimes students could not attend the sessions. I decided to be flexible over attendance. The module used small group, activity based learning strategies. Literature and art excerpts, case scenarios and role plays were used to explore the subject. The students were particularly interested in using role plays to explore various scenarios.

Creating a sense of belonging among the group of students was important. On occasions I distributed 'Thank You' notes to the students which had a photograph of a particular location in Nepal, very scenic country. Periodic assessments of the participants were carried out by the facilitator and constructive suggestions for improvement provided where required. We had a get together over tea and snacks at the end of the module. Group photographs were taken and the students were given a letter signed by the Dean of the institution and myself stating the various skills they had acquired during the module, as well as a certificate of module completion. The specific skills acquired were an appreciation of the patient perspective on sickness and health, awareness of the effect of sickness of a loved one on the caregiver, ability to break bad news gently and humanely, understanding of the patient-doctor relationship and recent developments on this topic, knowledge of the process of obtaining informed consent from the patient/patient's legal representative, and knowledge of the complex issues underlying abortion among others. Students were informed that they and their seniors on the clinical side were the first MH students in Nepal and their inputs and feedback would be useful for conducting future modules.

Sessions for clinical students at Pokhara

The sessions for the fifth and sixth semester students were held two days a week after 7.30 pm. Extra sessions were conducted when required. My colleague, Mr. P. Subish was kind enough to offer the meeting hall of the Drug Information Center (DIC) for holding the sessions. The place was comfortable and quiet and offered a relaxed and protected environment for the participants. The participants were interested in using role plays to explore issues in MH. They were also interested in using debates to explore controversial topics. The inputs and knowledge of the faculty participants was useful. Tea was served during the sessions. The discussions were free and frank and the teacher-student relationship was friendly. With the passage of time, the sessions became an intellectually stimulating get together of friends and colleagues. We had fun while learning!

'Thank you' notes and regular constructive feedback were provided to the participants. The participants also assessed the facilitator periodically. The sessions were conducted using a small group format. All the participants were staying on campus or nearby and the sessions could go on till late at night (around 10 pm). Pokhara is a small city and shuts down early except at the tourist hub of Lakeside. Though the module was not included in the formal curriculum and had no marks allotted to it in the examinations, the participants were beginning to understand the importance of the subject for their future practice.

Students who participated had an understanding of what sickness meant to the sick person and his/her family. They were able to consider sickness in the context of social, economic, cultural and family background of the sick person. In the hospital they witnessed the process of obtaining consent for various procedures and as they had already designed an informed consent form and discussed various aspects of the process of obtaining informed consent they were better able to understand and appreciate the importance of the procedure. During their Psychiatry posting they were more comfortable dealing with mentally ill persons and obtaining a psychiatric history. They had developed a historical background regarding improvements in the management of the mentally ill in Western countries and strongly felt the management of the mentally ill in health institutions and in Nepalese society as a whole should improve.

In Nepal for a long time abortion was illegal except in certain circumstances. Recently abortion has been legalized and women occasionally visit the Gynecology OPD at Manipal Teaching Hospital seeking abortion. Students who had taken the module were better able to understand various issues underlying abortion and the far reaching psychological effects it can have on the women and their families. Following the module students were more comfortable discussing issues of human sexuality. Nepal is a conservative society and these issues are not generally discussed; there is a great deal of secrecy and embarrassment associated with sexuality. Students who completed the module were able to discuss these aspects during history taking with patients and were able to put the patient at ease about these 'sensitive' topics.

Module for faculty members at KISTMC

KIST Medical College (KISTMC) is a new medical school in Lalitpur district of Kathmandu valley, Nepal. The management was interested in further developing humanistic qualities among doctors and faculty members of the institution. An Internal Medicine specialist, Dr. Piryani, was interested in MH and joined me as a co-facilitator. . The experience of the MCOMS module was useful in developing a module. The module was conducted during Sunday afternoons. (Sunday is a working day in Nepal where Saturday is the weekly day off.) The sessions were held in the 'Doctor's room'. We used PowerPoint slides to link together various activities and different aspects of the presentation.

I was apprehensive about dealing with faculty participants. The group was very diverse with basic science faculty, physicians, surgeons, dentists and medical and dental officers. Initially the module was conducted in a similar fashion to the pioneering one at MCOMS. However, the faculty members were not comfortable with role plays and felt it was childish. They were uncomfortable openly discussing issues of human sexuality. (4) They wanted the sessions to more closely reflect various issues and problems they encounter in practice. Regular participant feedback was obtained at the end of each session and informal feedback through interaction with participants.

Based on their feedback we decided to change the nature of the sessions. The number of role plays was reduced and group work and presentations were used to explore MH. During the session on 'Dealing with the HIV-positive patient' an example of group work given was 'Should HIV-testing be made mandatory before surgery in KIST Medical College? Should other patients in the ward be told that a particular patient is HIV-positive? Should commercial sex workers be registered and HIV testing be made mandatory for Commercial Sex Workers?'

KIST Medical College at the time had just started hospital operations and we wanted to obtain guidelines and standard operating procedures for the hospital also. Certain protocols linked to topics covered during the module were developed for further discussion. The group work and the activities were designed keeping in mind that participants were clinicians and faculty members. Another activity was as follows: 'An HIV-positive patient has been admitted in KIST Medical College. A batch of first year students has come to your unit for their weekly clinical posting. Chalk out a plan of action regarding how you will use the patient to teach students about dealing with the HIV-positive'. The presentations were about various procedures and mnemonics developed for 'Breaking bad news' and their applicability in Nepal, the effect of modern psychiatric medicines on the management of the mentally ill, and the effect of the prolonged conflict in Nepal on access to health facilities among others. Presentations were on medical humanities topics of importance in daily practice.

The literature excerpts were felt to be difficult by the participants and were discontinued. Each session concluded with a summing up by the facilitators regarding why the particular topic was important to practicing clinicians and medical educators.

Module for students at KISTMC

The author gave a presentation about MH to various faculty members (especially new members) and the college management. A case was made for teaching MH to medical students. The management was supportive and a MH module was started for the undergraduate MBBS students of the institution in February 2009. The module was planned using the experience gained at MCOMS and at KISTMC. Valuable inputs were offered by international experts like Dr. Johanna Shapiro and Dr. Huw Morgan. Dr. Morgan was a cofacilitator for certain sessions.

The module is held every Wednesday from 8 am to 9.30 am. A big room at the top floor of the hospital is used for the sessions. The room gives us the flexibility to arrange seating according to our requirements. Mikes and speakers and a central area for conducting role plays are present. Flip charts and the LCD projector are used. The students are divided into various groups. Considering previous feedback literature excerpts are not used. To explore MH, paintings-which do not have the cultural and linguistic barriers associated with literature-are used, as well as group work, case scenarios, and debates.

The module is activity-based and all 75 first year students attend. Considering the large student number and the need to develop new facilitators for this and future modules, six clinical and basic science faculty members were selected as cofacilitators. Various innovations have been carried out during the module to maintain participant interest. Music I feel is a powerful means for exploring MH so songs and music are part of the session these days. We have devised an activity where the student group sign a song or recite a poem about a scene depicted in a painting. The facilitators often join in! Most sessions have an 'Open Space' (Khula Manch in Nepali) were the participants recite poems and sing songs on various topics.

Thus I have used a variety of approaches to maintain interest in Medical Humanities among both student and faculty participants. It has been a challenge to maintain interest in a subject which is not a formal part of the curriculum and which is not assessed. However, I have relished taking up the challenge!

References:
1. Shankar PR. A voluntary Medical Humanities module at the Manipal College of Medical Sciences, Pokhara, Nepal. Family Medicine 2008; 40:468-70.

2. Shankar PR. A Voluntary Medical Humanities Module in a Medical College in Western Nepal: Participant feedback. Teaching and Learning in Medicine. 2009;21:248-53.

3. Shankar PR. Running a voluntary module - Personal experiences. Journal of Medical Sciences Research. 2007;2:55-58.

4. Shankar PR. Design the shoe according to the foot! The Clinical Teacher 2009; 6:67-8.

The Story As Chameleon: A Transformation

September 14, 2009 at 9:26 am

A chameleon sitting on a branch of a tree. Colour half-tone. 1926.

Commentary by Patricia Stanley, M.B.A., M.A., Guest Faculty, Program in Narrative Medicine, Columbia University’s College of Physicians and Surgeons; Clinical Coordinator, Masters in Narrative Medicine

There is a short story, "The Shawl", by Louise Erdrich, which is about story and memory and the reworking of old stories into new ones to effect healing. (1) A story of a child being thrown to the wolves is transformed generations later into the child's heroic leap to save a family, the tribe, the pride of the reservation. This story has particular meaning for me since I too have transformed a tragic story from a past time of much suffering into a reason to heal and to bring healing to others through my work as a health advocate. As Arthur Frank writes in The Wounded Storyteller (pp. 23-24):

To think with a story is to experience it affecting one’s own life and to find in the effect a certain truth of one’s own life . . . Being responsible to these stories, thinking with them, depends on telling certain stories over and over, hearing different nuances of potential meaning as the story is told in different circumstances and at different ages of our lives.

The Beginning

After my husband's death from a ten year battle with cancer, I was beset by loss, the loss of my husband, the loss of my old life. I needed a new purpose. I also was haunted by images of patients, alone and isolated as they tried to navigate the medical maze of specialists, community hospitals and urban teaching medical centers, insurance regulations, clinical trials, endless interventions and medical decision making. Towards the end of that decade, a small seed for a new beginning was planted after a doctor remarked: "You know, you should consider becoming a patient advocate." And so in January, 2002, I enrolled in the Masters in Health Advocacy Program at Sarah Lawrence College under the expert guidance of Marsha Hurst and began my transformation from a Westchester widow to an agent for change. That summer, I took Sayantani DasGupta's popular course: "Illness Narratives: Understanding the Experience of Illness." There I found my niche in the new literary genre related to memoir and autobiography called illness narratives or pathography.

As part of the grieving process and finding meaning in my new life and in need of developing skills to help others as an advocate, I developed an insatiable thirst for these stories of suffering. They became a way for me to connect to the embodied suffering that I had recently experienced with my husband. In this class I witnessed the healing that develops from the process of writing in which patients discover their story of survival, move it from talk to the visible page, where they can recover, revise and thereby control the meaning of what has happened to them. I experienced how writing and sharing a story enables a person to feel the connection with stories that reach beyond one's own personal story, a connection to something larger than oneself. Witnessing these stories enabled me to understand the many variations on suffering and to respect the connections and the differences that each story evoked. Most importantly, I felt that I was not alone with my experience but that I was part of a community.

A Door Opens

I was hooked. Because Sayantani included a fair amount of narrative theory in the syllabus, I became acquainted with and actually quite dazzled by the writings of Rita Charon. I asked Sayantani for an introduction to the veritable source of "narrative medicine," not once but at least twice to see if I could become an intern. I also repeated Sayantani's course in the fall to take advantage of a more complete syllabus than was given in the intensive six week summer course and an additional oral history project. That winter and spring, I helped a Sarah Lawrence economics professor teach Economics 101 to inmates attending the college at the Bedford women's correctional facility. That experience fueled my interest in stories, how they are ever so singular while still so clearly part of the common human fabric.

Fortunately the next summer Rita Charon had been awarded an NEH grant to develop a curriculum to train health care providers with narrative competence. I met her and she took me on as an intern to assist in the coordination of that grant and to help in whatever way possible with the seemingly endless list of projects in which she was involved. I have never left.

The oral history project that Sayantani DasGupta assigned in that fall course began another interest and passion for interviewing and recording the stories of others, primarily those involved in some way with illness. I did a capstone project for my Masters which was to conduct oral histories of patients from the Dickstein Cancer Center. I interviewed, recorded, transcribed and wrote their interviews and gave each patient both the oral and written narratives for their own use. I was astounded by how eagerly they talked to me, sharing hours of memories, reflecting on the meaning of illness in their lives. This oral history thread has continued to be a significant part of my narrative work.

Field Work in Narrative Medicine

I have been immersed in narrative medicine since the summer of 2003. As part of Rita's NEH project, I became a member of the faculty that facilitates the annual workshops conducted by the Program in Narrative Medicine to train outside healthcare providers and others in the art of narrative competence. I have also been part of the planning process for the Masters in Narrative Medicine which begins this fall at Columbia. Based upon my fieldwork that I will describe in the next few paragraphs, my ongoing role for the Masters will be to supervise clinical internships for the students.

After I graduated from Sarah Lawrence with a Masters in Health Advocacy, Rita offered me an opportunity for my own workshop with patients. I had had a previous opportunity one summer to co-facilitate with Rita a narrative intervention with the doctors, nurses and social workers on the pediatric oncology floor at Morgan Stanley Children's Hospital (CHONY). I also had sat in on narrative rounds, a thriving biweekly group of clinicians, nurses and social workers from the oncology floor at NY-Presbyterian Hospital who wrote together about their clinical experiences and read to one another what they had written. From this experience came the idea to add the patient's voice. Rita offered me the chance to begin a narrative writing workshop that combined oncology outpatients with family caregivers and clinicians. One oncology doctor had funding from the patient foundation, Team Continuum, and an oncology social worker was eager to co-facilitate. We put up flyers and sent out the call for participants.

As a result, one Tuesday evening in September 2006, thirteen courageous people arrived on the sixth floor of Milstein Hospital in search of something called a narrative writing workshop. That first year the group was composed of all women: one oncologist, two nurses, two caregivers and seven patients. We read together Rita's book, Narrative Medicine and excerpts from illness narratives. We wrote at each monthly meeting and shared our writing, and we became a community. Let me quote from one of the members:

Do not be deceived, this is no ordinary group…There is no doubt they lost a lot, almost everything, but they found the strength to come together to talk, to write, to read, to trust again, and to continue living.

With the ongoing financial support of Team Continuum, we planned the second year, invited some guest speakers and ventured forth to see a movie together, The Diving Bell and the Butterfly.

Now at the end of our third year, our workshop has 19 members and a waiting list. We are a diverse group including patients who are in remission and patients who are in active treatment, patients who are living with chronic illness and those who are just now experiencing the pain, fear and loss of control owing to a new diagnosis or a recurrence. We have doctors, nurses and social workers; we have members who fit into several categories simultaneously: clinician, patient, bereaved persons. And we have men and women.

We have read together a wide range of work from Joan Didion to Marcel Proust; explored visual art from master paintings to comics; shared our favorite songs; and every session we write together is all in the service of using art to inspire creative exploration of the experience with chronic illness and loss.

We have expanded the program to include some daytime events that gather additional patients, caregivers and clinicians around a table making books, writing poetry, combining text and art through collage. We have put poems in the waiting rooms on the oncology floors for patients and families to enjoy and take home.

We have expanded our team of facilitators to include an artist, a poet and a writing coach who have in turn inspired members of the narrative writing workshop to put together a book, Inspiration, an anthology of poetry and prose, photography and collage. In June, we held a reading event at the hospital during which members read from the book to an audience of 100+ doctors, patients, family members, friends, and colleagues. Copies (1000) of the anthology have been dispersed far and wide to other hospitals, clinicians, families and patients. This workshop is fully funded for the coming year and the members are eagerly working on another book.

Fieldwork: Oral History, a Narrative Application

My interest in oral history has been a constant thread in the fabric of my narrative work. I am in the process of conducting a series of oral history interviews with the past president(a reign of 40 years) of Blythedale Children's Hospital in Valhalla, NY. He transformed Blythedale from a small convalescent home into the highly regarded independent children's rehabilitative hospital that it is today. The oral history thread also led me to initiate the weaving of a video story project into the curriculum at the Mt. Pleasant Blythedale School. The students at this Special Acts District School are all patients of Blythedale Hospital. This project is based on the StoryCorps model and in fact the school has become a community member with StoryCorps. Parents and children have recorded interviews in the StoryCorps booth at Grand Central Station and at the school. An oral history expert from Columbia University's oral history department has trained the teachers on the use of oral history in a secondary school curriculum. We have built a video story studio and have received a grant from Pace University to purchase professional video equipment, computer and editing software. The project has become a multi-pronged initiative incorporating the idea of story, listening, interviewing and writing throughout the curriculum giving the students the skills and opportunity to advocate for themselves, to give voice to their feelings and to utilize narrative competence for any number of creative and useful projects.

Full Circle

In "The Shawl," the narrator at the end of that saga of suffering says:

Now, gradually, that term of despair has lifted somewhat and yielded up its survivors. But we still have sorrows that are passed to us from early generations, sorrows to handle in addition to our own, and cruelties lodged where we cannot forget them. We have need to forget. We are always walking on oblivion's edge. (1)

My experience with narrative medicine and with the video story project at Blythedale has become my new story, one of survival from a tragic experience of personal loss. The sorrow is still there but something so strong and affirming as this work in narrative medicine has given me a healthy distance from oblivion's edge. For that I am most grateful.

NOTE: I found the metaphor for the title of this commentary in Sherry Reiter's new book: Writing Away the Demons: Stories of Creative Coping through Transformative Writing (St. Cloud: North Star Press, 2009) p.257.

Reference 1. Erdrich, Louise, "The Shawl". Literary Cavalcade, May 2002 54 (8): p.23.

 

Is Medical Uncertainty Necessary?

August 31, 2009 at 9:40 am

Artist: Neil Leslie

Commentary by Caroline Wellbery, M.D., Associate Professor of Family Medicine, Georgetown University Medical Center; Associate Deputy Editor, American Family Physician

Medical uncertainty is all around us

AIn medicine we are quite often confronted with 'not knowing,’ with 'choices,’A with 'multifactorial etiologies,’ and 'inconclusiveness,’ to name just a few of the states to whichA we can apply the term 'medical uncertainty.’A Although nothing new, the idea of medical uncertainty might recently have become more fashionable as clinicians have begun to ponder the limits of evidence-based medicine. As appealing as it is to have incontrovertible scientific backing for our actions in treating our patients, we often simply don’t know what to do.

A search in Pub Med using the term medical uncertainty yields several thousand articles. Of those that might be relevant to this essay, the articles range from philosophical speculations to the calibration of laboratory standards. There are articles about prognosis, about patient ambivalence, about the interpretation of guidelines and the changing scientific base of clinical practice. In other words, medical uncertainty is pervasive, perhaps astonishingly so, considering that most of us who practice medicine proceed confidently in our daily decisions and interactions. I recently asked a colleague who sees patients on a regular basis whether she ever feels uncertain as a clinician. "Sure," she said-confidently, I might add-"But a lot less nowadays than I used to."

I would submit that in daily medical practice, there is a constant measure of low-level uncertainty. This uncertainty can increase when the stakes are higher-a patient is seriously ill-or when the psychological and social context of the situation potentiates the uncertainty. In such cases, clinicians will usually seek validation or consensus from colleagues, or even from formal organizations such as ethics committees.

None of this, though, addresses the question of what, if anything, we can learn from medical uncertainty, or whether, God help us, there is any value to it. On the surface, we live by the contrary: we assume that medical uncertainty is an obstacle that prevents us from providing the best medical care. If the US Preventive Services Task Force states that evidence is 'insufficient,’ for example, in determining whether to do prostate cancer screening or not, this leave the practitioner with 'no answer,’ a situation that can be personally frustrating and legally dangerous.

But one thing I have noticed is that as long as medicine is a job, there is a tendency to focus on doing, whereas when medicine is a calling, the focus also incorporates being. So while medical uncertainty gets in the way of doing, I would argue that it actually has some utility in fostering that aspect of medicine that involves being. The reason for this, as I shall explain, is that uncertainty in medicine allows for a philosophical reframing of clinical intervention when conventional 'doing’ has little to offer. But in order to understand what exactly medical uncertainty has to offer us, we must first acknowledge that some sorts of persons have a higher tolerance for uncertainty than others.

Uncertainty and temperament

One of my favorite poems is David Gewanter’s "My father’s autopsy," because it captures so much of what, in medicine, is science, and what of it is art. The father of the poem’s title is a pathologist. When his son turns 13, the father decides that he is of an age to accompany his father to the morgue to witness an autopsy. It’s an initiation rite that invokes Jewish tradition, associating the thirteenth birthday with the advent of manhood and, by extrapolation, with the knowledge of death. But father and son have wholly different views of the world. The father sees a corpse; the son wonders about her sexuality. The father saws open the body; the son sees a jumble of metaphors. The father pulls out a pebble from the dead body, presumably the cause of death and, satisfied with the explanation it offers, replaces it. The son, though, is horrified at the disturbance of the body’s integrity. He wishes she had never said 'ahh for a doctor.’ He implies that you cannot put back a pebble as though nothing had changed.

In short, the father delights in the objective findings of the dissection, in capturing the anatomical cause of death. The son in turn thinks only of subjectivity-his own, his father’s, and the dead woman’s. He is not interested in reducing the death to a cause. He is interested in the complexity of the subject and indeed, turns his attention to his father, with whom he has a complicated relationship. His 'autopsy’ of his father yields anything but a pebble. It yields an opaque human being, as 'inward as a microscope’. The father remains elusive to the son’s tools of dissection.

What we have in this poem are essentially two types of people. The father devotes himself to clarity and objectivity. He hates mess. The son revels in uncertainty and ambiguity. The wholeness, impenetrability and multiplicity of the body are the stuff of poetry. What does this say about medical uncertainty? It suggests that much of medical uncertainty has to do with the practitioner him- or herself.A There are those who lose themselves in the objective findings and require concrete and coherent answers. Then there are others for whom the essence of inquiry relates to the dense, opaque and mysterious qualities of subjectivity. These are two realities, and I believe that physicians align themselves with one or the other, with the one important difference that unlike the poet narrating the poem, the metaphorically inclined doctor cannot discount objective reality.A But objective action and findings for the 'poetic’ physician are not what he or she finds most compelling in medicine.

Comfort with uncertainty drives specialty choice

A story, "The Save," recently published in Pulse, Voices from the Heart of Medicine tells this story.AThe surgeons devote themselves to reattaching a limb that the patient has deliberately sawed off. They ignore the psychiatric disorder that led to this self-mutilation and then are shocked when the patient tears off the repaired limb after surgery. The narrator, on the other hand, decides at that moment that he is more suited to become a physician of the 'whole’ person than a surgeon. It is perhaps telling that the narrator speaks of the 'whole’ person in the setting of this self-mutilating dismemberment. The 'whole’ presumably refers to the many factors and influences that led to the patient’s inner torment, but also echoes Gewanter’s interpretation of 'wholeness’ as something that is ultimately inaccessible, if not imponderable.

Wholeness, then, and uncertainty bear a degree of kinship, because the objectively focused physician can usually find some part of the whole that can be addressed with certainty, even when the problem of the 'whole’ remains uncertain. As a simple example, a cancerous bowel can be surgically excised, but the impact on the patient and his prognosis remain uncertain. Thus, I think it is safe to say that some practitioners are at home with uncertainty, whereas other require definitive answers, and that these differences in temperament dictate choice of specialty.

Uncertainty invites [other] answers

This leads me to an important corollary insight: if some practitioners by temperament gravitate towards medical certainty, and others gravitate towards uncertainty, then patients whose problems have certain outcomes will best be served by the former and patients whose health is rooted in ambiguity will benefit from care by a holistically oriented practitioner. The latter patient, as I try to tell medical students, is by far the most common. I see their disappointed faces as they begin to suspect-but quickly dismiss-the probability that most of what doctors do is help patients navigate ambivalence, complexity and the unknowns of their illness. This state of affairs is not as dire as they imagine. These practitioners do not lose competence or confidence in the setting of uncertainty. Rather, they ride the uncertainty as a necessary part of care, even of life, and at times, experience their richest moments in pondering its mysteries. This brings me then, to the question of whether uncertainty is necessary, or even desirable.

That the speaker’s answer to this question in David Gewanter’s poem is in the affirmative is clear from the title.A "My father’s autopsy" revels in the ambiguity of meaning: is the father dissecting a corpse (in fact that is what the poem goes on to show) or is it the father who is undergoing the autopsy (it turns out that this, too, is true, albeit metaphorically). While in medicine we cannot do without the objective treatment or cure, the absence of the interpersonal layer often leaves the patient bereft of hope or meaning. The very essence of uncertainty is 'both and.’ By acknowledging that uncertainty is an inevitable part of clinical care, the poetic, 'both/and’ type of practitioner can reframe the patient’s priorities, moving the patient away from the need for certainty to an understanding of what, in the larger scheme of things, is important.

No poem expresses this reframing so well as Veneta Masson’s "Reference Range." In this poem, the practitioner discusses lab results with a patient. Already early on, the significance of the lab results are called into question:

Your tests show

the numbers 73, 90, 119 and 2.5,

the letter A,

the color yellow,

a straight line interrupted by a repeating pattern

of steeples and languid waves

The patient balks at the explanation. The patient wants to know what the lab results mean. Are they normal, he asks. Again the clinician responds by emphasizing the numerical uncertainties. This time, she goes on to reorient the patient. We can’t know what these numbers mean, exactly, she appears to explain. But maybe their exact meaning, in the context of this visit, or this illness, aren’t all that important. Maybe the focus should be on what really is important, a focus that eludes objective medical attention. Laced throughout the poem are hints at this sort of elusive focus: the color yellow, a squiggly line. The poet concludes by saying:

Normal’s a shell game you seldom win.

Take my advice. Enjoy good health

not as your due but the blessing it is

like Spring, laughter,

death.

Conclusion

Medical uncertainty indeed takes many different forms in clinical practice, and is almost an integral part of its vocabulary. Whether they are aware of it or not, practitioners deal with uncertainty every day, and it becomes a problem mostly in serious and complex situations which require consultation with others. That being said, some practitioners are, by temperament, more comfortable with uncertainty than others, and these individuals, like the provider in Veneta Masson’s poem, can turn medical uncertainty to their advantage by redirecting patients’ priorities. So is medical uncertainty a necessity? Certainly to some technicians and specialists, it is a necessary evil. But to others, particularly in the patient-oriented specialties, medical uncertainty is also an opportunity.

The Healthcare Debate And Disability Studies

July 29, 2009 at 9:26 pm

Neil Leslie, Wellcome ImagesMedicine - diagnosis and treatment, Digital artwork/Computer graphic

Two related items in the Science Times section of Tuesday’s New York Times (July 26) drew my attention. One was Dr. Abigail Zuger’s book review of Normal at Any Cost by authors Susan Cohen and Christine Cosgrove and the other was an essay entitled "To Overhaul the System, ‘Health’ Needs Redefining," by Dr. H. Gilbert Welch. What these articles have in common is that both ask us to re-examine what is meant by "normal health." And both articles raise this issue in the context of current national discussions about runaway health care costs.

The book that Zuger reviews deals with "the medical industry’s quest to manipulate height" using growth hormone. Zuger notes that "the boundaries of ‘normal’ height are hazy, and the drug’s performance is measured only in averages." According to Zuger, the book’s authors deduce that every inch of growth gained by hormone treatment costs $50,000. As height is increasingly manipulated to satisfy social standards as well as pharmaceutical and medical profits, costs rise; of equal importance is the failure to promote social acceptance of a wide range of heights.

Gilbert Welch frames his argument more generally. The "medical-industrial complex" needs patients and so it defines health as "the absence of abnormality." Increasingly, the range of normal has been narrowed. But "more often than not, the value of treating . . . mild abnormalities is simply not known" and physicians in training "are increasingly confused about who is really sick and who is not."

Questions about the definition of normal, about who gets to define "normal," and about the medicalization of the body are at the core of disability studies scholarship. So it would seem that in the debate about health care funding and cost control, some of this scholarship needs to be injected. Policy wonks and legislators should be aware of this body of work. In the context of these two articles we could point them to the work of those who have addressed these issues for more than a decade. For example, Robert Aronowitz demonstrated in 1998 that disease definitions are influenced by the vested interests of physicians, researchers, and policy makers in the biomedical enterprise and are not immutable biological entities, disconnected from their cultural context (Making Sense of Illness: Science, Society, and Disease. Cambridge: Cambridge University Press, 1998, pp 11-14).

Lennard Davis discussed statistical norms: "When patients are treated they are not treated as individuals but as instantiations of norms. . . While normalcy requires that I appear in person as an individual before my health care giver, I am treated by reference to laboratory and statistically determined medical norms. A good deal of the energy of being alive becomes devoted to this imperative to conform physically." (Bending over Backwards: Disability, Dismodernism and Other Difficult Positions. New York: New York University Press, 2002, pp. 115-116).

Kathryn Pauly Morgan developed a medicalization model of pregnancy (conception, gestation, and birth) in North American culture. (Contested bodies, contested knowledges: Women, health, and the politics of medicalization. In S. Sherwin, ed., The Politics of Women’s Health: Exploring Agency and Autonomy. Philadelphia: Temple University Press, 1998, pp. 83-122.)

Susan Wendell outlined the social construction of abnormality and disability: "Disability is socially constructed through the failure or unwillingness to create ability among people who do not fit the physical and mental profile of ‘paradigm’ citizens." (The Rejected Body: Feminist Philosophical Reflections on Disability. New York and London: Routledge, 1996, p. 41).

Also relevant are "The Meaning of Normal" by Philip Davis and John Bradley in What’s Normal?A eds. Carol Donley and Sheryl Buckley (Kent, Ohio: Kent State University Press, 2000, pp. 7-16) and selections from The Tyranny of the Normal, eds. Carol Donley and Sheryl Buckley (Kent, Ohio: Kent State University Press, 1996)

And all of us should remember Paul Starr‘s important book, The Social Transformation of American Medicine, published in 1982.

Felice Aull

Summer Blogging: Traveller’s Joy

July 20, 2009 at 3:58 pm

Traveler's Joy

We are taking a break from our regular essay commentaries until September.A In the meantime, there will be occasional short postings, mostly by me (Felice Aull). This image of the plant, Traveller’s Joy, invokes this summer interlude — the pleasure of enjoying gardens, parks, nature (at least in the northern hemisphere) and of vacation traveling, but also the possibilities for intellectual travel, creative travel, and other explorations beyond familiar borders. Here are some thoughts to begin with.

We learned today that author, Frank McCourt, died on Sunday, July 19.A His memoir (creative nonfiction?), Angela’s Ashes, is one of the most compelling, absorbing, and entertaining books that I have ever read (and I read a lot). I was moved to annotate it for the Literature, Arts, and Medicine Database as soon as I finished reading it in 1996, and before it won The Pulitzer Prize and the National Book Critics Circle Award. In addition to being well-crafted and devastatingly sad, it was witty-a rare combination. But the book and its author pulled me into their orbit for additional reasons.

McCourt had taught for years at Stuyvesant High School, an intellectual rival of my own alma mater, the Bronx High School of Science, and located just a few blocks from where I live — until it moved to its present location near Battery Park City. Not only that, but somehow I found out that Frank McCourt LIVED a couple of blocks away from me, in a nondescript apartment building. I wanted to contact him to invite him to be a speaker in the Literature, Arts, and Medicine Speaker Series sponsored by NYU School of Medicine, where I taught and organized the series. He could speak, I thought, about deprivation and resilience, humor and illness, writing and the self, the human condition. Among the medical students and faculty he would be addressing were many who had graduated from Stuyvesant High School, and some who even remembered him as their teacher.

I don’t remember how-probably just by searching the phone book-but I found his telephone number. When I called, a pleasant woman answered the phone and said she would give him my message. I waited several weeks without hearing from him and phoned again. This time, there was an answering machine that gave out very little information. Apparently, the book had taken hold, publicity was churning out, and his life was no longer confined to East 18th St. His gain, and our loss. I never read the books he wrote after Angela’s Ashes — I didn’t want to spoil the pleasure that book had given me.

Celebrating July 6

July 6, 2009 at 10:21 am

Scan of an article -

Commentary by Bert Hansen, Ph.D., Professor of History, Baruch College, The City University of New York. Author of Picturing Medical Progress from Pasteur to Polio: A History of Mass Media Images and Popular Attitudes in America (Rutgers University Press, 2009).

In people's minds, July 6 rings no bells. It lights no anniversary fireworks. Yet we all live in a world of new discoveries, headlines proclaiming new cures, and the persistent expectation that new advances will keep coming. Those key features of the modern world were born on July 6, 1885, in a revolutionary shift in ordinary people's expectations. An old-style medicine that honored white-haired doctors and traditional practice at the bedside was quickly replaced with one characterized by novelties born in laboratories.

The atomic age is readily dated to August 6, 1945, when the bomb exploded over Hiroshima. Biology celebrates November 24, 1859, the publication date for Charles Darwin's Origin of Species. Molecular biology celebrates 1953 for the journal article in which James Watson and Francis Crick proposed their double helix model for the structure of DNA molecules. In 1955, headlines blared "Victory over Polio: Salk's Vaccine Works." Yet Salk's shots were not the start of laypeople's enthusiasm for medical advance, they stood in a tradition that began with another kind of injection in the late nineteenth century.

The medical revolution began very quietly in Paris on July 6, 1885, with the first human test of shots to prevent rabies a a relatively uncommon, but widely feared and absolutely fatal disease. Nine-year-old Joseph Meister, mauled on July 4 by a rabid dog, received the first of thirteen injections with a vaccine not yet tested in humans. Louis Pasteur, who developed the remedy, was nervous, and none but his most trusted laboratory associates were present. For about three months there was no publicity.

But within six months a largely caused by events in the United States a headlines around the globe carried news of a medical triumph such as the world had never seen. Children threatened with a horrible death from rabies were saved by these new injections. For the miracle cure, thousands of people bitten by dogs and wolves flocked to Paris from the Americas, eastern Europe, north Africa, even Siberia.

Media coverage in the United States played a unique role in creating a popular enthusiasm for the cure and a new idea of medical progress, both here and aboard. New tools of journalism were at hand: banner headlines, the reporter's interview, the human-interest story. Cut-throat competition among the penny papers produced an incessant drive to collar readers with exciting stories and to grab them again the next day with new developments.

Story-hungry papers were ready to pounce in December, when little children in the streets of Newark were bitten by a mad dog and a local doctor's letter to the editor suggested they be rushed to Paris for the new cure a with donations from the public if their parents could not afford it. Within hours factory employees were collecting loose change and delivering it to the doctor's office. Within two days, papers as far distant as Chicago and St. Louis reported the bites, the donations, and a trip to Paris in the offing for four working-class boys. The story was an editor's dream: innocent children threatened by an agonizing death, public charity, the problem of stray dogs, doctors and scientists to be interviewed, and a voyeuristic story of the boys' transatlantic voyage

Artists produced sketches of the boys, the dogs, the local doctors, M. Pasteur, and the steamship. Papers added editorials on science and long articles about Pasteur's earlier discoveries. The over-the-top coverage was quickly parodied with color cartoons in the weekly humor magazines, Puck and Judge. Much of the news coverage was silly and might have been ephemeral but for the fact that there emerged within it one entirely unprecedented image a the heroic scientist creating medical advances through laboratory research. The public became religiously devoted to this figure.

A rabid dog in Newark produced something no publicist could have achieved. And while the media bonanza was most striking in the United States, medical advance gained similar attention in other countries through the new rabies shots being given in Paris. Within three years, world-wide donations from schoolchildren and from princes built the Pasteur Institute in Paris, followed soon by a score of daughter institutes around the world.

Last year when two Pasteur Institute scientists received the Nobel Prize in Medicine for their identification of the virus responsible for AIDS, the world applauded them for a major breakthrough of modern medicine, a discovery that depended on a tradition just a little more than a century old, the powerful institutionalized process of research and development.

It all started when a boy was injected with weakened virus to save his life. He lived, he thrived, and he became a media celebrity.

In appreciation for rabies shots a but even more for the role of the press in creating the new idea of medical progress, let us all celebrate July 6.

Interesting Lectures Online

May 27, 2009 at 12:28 pm

The University of North Carolina School of Medicine’s Bullitt History of Medicine Club held numerous interesting talks in 2008-2009 that are available online at their site.

Felice Aull