Teaching Medical Listening Through Oral History

July 24, 2008 at 8:46 pm

The story of the Bhagvadgita.

Commentary by Sayantani DasGupta, M.D., M.P.H., Assistant Clinical Professor of Pediatrics and Core Faculty, Program in Narrative Medicine, Columbia University; and Faculty, Graduate Program in Health Advocacy at Sarah Lawrence College

The mystery of illness stories is their expression of the body: in the silences between words, the tissues speak. It’s about hearing the body in the person’s speech. — Arthur Frank(1)


Hearing the Body

A woman with a history of thyroid cancer is giving a life history interview to a student as part of a graduate seminar assignment. Her narrative shows how complex and interworven the pieces of an individual’s story are to one another. "My parents never felt strong enough to share with me that I was adopted," she reveals, "but deep down I had an inkling that was the case…I recall my mother, who had a separate walk-in closet from my father…saying to me many times over, 'You’re welcome to try on my clothes…but never touch the strong box that’s on the shelf because it contains important papers related to our house.'" At age 12, she finally opens the box, discovering the truth of not only her parentage - in the form of letters between her adoptive and biologic parents - but the key to her genetic health risks. When, years later, after having a child herself, she decides to contact her biologic mother, she discovers that her mother is terminally ill with ovarian cancer - 20 years after having had breast cancer as well - and that she herself is genetically predisposed to both diseases. (2)

Another student interviews her elderly father, a brittle diabetic who is slowly losing his ability for independent living. She compares him to Jean-Dominique Bauby, the completely paralyzed author of The Diving Bell and the Butterfly(3), describing her father’s condition as "The locked in syndrome of the aged." She both celebrates her connection to him and mourns his losses - present and future. "Sustained by memories, reflections and dreams and the adventures of the wanderings of the mind," she writes, "time will be fleeting and yet it will be all that he has…I know there is 'no currency strong enough to buy his freedom back from the kingdom of the sick.'"(4)

A young woman interviews her cousin, a man with a life threatening peanut allergy. She admits to her instructor that she picked her cousin for his sense of humor - "I didn’t want my illness interview to be depressing." Yet, although she has known about her cousin’s illness her entire life, the interview process inspires her to advocate for the safety of those with food allergies. Using Arthur Frank’s precept of living for others and 'placing oneself within the community of pain,'(5) she writes, "What Frank is advocating, I believe, is empathy - a quality that shouldn’t just translate into feeling but also action…I hope to carry on (my subject’s) message, combining both our voices into one, action oriented campaign.(6)

For the past seven years, I have taught a class on illness narratives at the graduate program in Health Advocacy at Sarah Lawrence College, a class in which students read autobiographical as well as scholarly writing about illness. The idea of teaching listening through the close reading of narratives is one that is consistent with my work at the Program in Narrative Medicine at Columbia University, where my colleagues and I teach medical students, residents, fellows, and practicing clinicians the skills of medical listening through the close reading of texts, as well as the writing and sharing of the students’ own texts.

However, the final assignment for my illness narratives class deviates from this tradition in medical humanities to use either literary or cinematic narratives in our teaching. Rather, I turn to the discipline of oral history to assign the students the task of conducting, transcribing and analyzing an oral history life story interview of a subject with a chronic illness. Before describing some more details about this exercise, it is useful to describe some ways oral history theory can illuminate our understanding of medical listening.

What is Oral History?

 

Oral history emerged in the wake of World War II, when historians in Italy and Germany became particularly interested in hearing the experiences of Nazism and Fascism from the voices of the people - realizing that the experience of the ordinary worker was not that which was recorded in the official history books. Oral history as a discipline focuses on "the interviewing of eye-witness participants in the events of the past for the purposes of historical reconstruction."(7). In addition to this broad-ranging understanding of individuals in their social and historical contexts, oral history is a field with a strong focus on individual voice and individual story - particularly the voices of the marginalized, oppressed or those otherwise "hidden from history."(8)

Oral interview as event

Oral history recognizes the interview as a unique event that can neither be reproduced at a different time or with a different interviewer. The uniqueness of the interview event is determined by the relationship of interviewer to interviewee, the nature of the questions asked, and perhaps, as esoteric factors as the time of day, directly prior occurrences, and cues of the physical environment.

Oral stories as meaning making processes

Oral history lends a qualitative understanding to oral stories - such that oral stories are not storehouses of confirmable 'facts,’ but rather, meaning making processes in and of themselves. Retrieving memory and constructing tellable stories are complex acts that reveal much about the teller’s sense of the world.

Oral stories as multivocal

Oral history recognizes oral stories as multivocal(9) and co-created by both teller and listener. Not only the questions asked, but the responses and reactions, body language, and very identity of the witness fundamentally shapes an oral narrative.

The oral interview as an "experiment in equality"(10)

Oral history is concerned with the possibility of interview bias secondary to issues of power and hierarchy - ensuring that the interviewer doesn’t impose their expectations upon the teller, guiding and determining the story. Simultaneously, oral history recognizes that no listener is 'objective,’ but that an awareness of her own filters and belief systems, as well as a degree of transparency, is necessary with the interview subject. I have made, in another location, an argument that such mutual transparency is fundamentally necessary to medical dialogue and practice.(11)

An Oral History Exercise

The oral history exercise I have designed for my health advocacy graduate students is a way for them to see 'narrative in motion’ - not only applying the theoretical ideas we discuss in class, but using some of the autobiographical texts we read to deepen their understanding of their oral history interviews. This multi-part, all semester assignment includes choosing a willing individual (whom they either personally knew or a willing stranger), constructing guideline questions, conducting a 45-60 minute taped interview of the individual, transcribing the tape verbatim, and then writing a paper which covers both the process of the interview and the themes which emerge from the interview. As a class, we construct an unofficial 'informed consent’ form, which details for the subject the solely educational purpose of the project, the ability to choose anonymity, and what will happen with tape, transcript and paper after the project is complete. Importantly, students present their oral histories to one another at the end of the semester, often, with their interviewees’ permission, playing samples of the audio (or video) tapes for the class. These sessions allow the individual life story interviews to become a collective series of oral histories - whereby one voice echoes another, certain themes resonate, yet, as opposed to statistical 'data’ - each subject’s particular, idiosyncratic voice remains intact.

This exercise has been adapted for Sarah Lawrence’s graduate program in genetic counseling, where genetic counselors in training interview pregnant women on, among other things, their ideas of hereditability.

The transformative power of an oral history exercise

This past year, I learned from a gifted student how much this exercise teaches listening and witnessing - even in the absence of a strictly ORAL narrative. Marleise Brosnan, a graduate student in the Sarah Lawrence Health Advocacy Program, conducted the first completely nonverbal oral history I have ever had in my class. When she approached me with this challenge, I wasn’t sure how to recommend she proceed, but encouraged her and her subject to find a way of completing the assignment. And so, my student interviewed her ex-husband Casey, who has had amyotrophic lateral sclerosis (ALS) for 5 years, been nonverbal for 6 months, with a tracheostomy and feeding tube, and only the use of his head and left hand. Marleise and Casey met on multiple occasions - far more than the required one visit interview - during which she would ask questions, then often spend hours interpreting - and confirming her interpretations of - his facial expressions, nods, vocalizations, and laborious handwriting- a process not unlike that which Jean-Dominique Bauby underwent in writing The Diving Bell and the Butterfly.(12)

The impact of watching one of Marleise and Casey’s interview sessions on videotape was profound for the rest of the class. Part of that impact was Casey’s physical presence - his handsome face, his disobedient body, the tracheostomy tube, the wheelchair. The majority of the impact, however, was witnessing Marleise and Casey’s profound connection over his story - her dedication to facilitating his 'voice’ and his to being 'heard.’

"I am waiting for freedom," wrote Casey on a lined 81/2 x 11 page that Marleise held horizontally before him, "from either a cure or death."

For my student Marleise, the experience of witnessing and co-authoring Casey’s story served several scholarly and personal functions. In her words,

"I recognize that I put my feelings about his disease in a box - and I put that box all the way in the back of my mental attic and stacked several other boxes on top of it. I know a day will come when this box will be opened and I will be faced with a mountain of sorrow related to his life and death…never once have I shed a tear. I cannot. For I know that if I shed one tear, all the tears in the box will come pouring out and just may consume me..I am conducting this interview in preparation for that day. So that when the day comes I will have not only participated in his care, but will have made a connection for him to the world after him and a gift to leave behind for his sons. I feel this exercise for some reason will also help me bear the weight of the immense grief and loss to come."

Conclusion

"Oral history interviews are unique in that the interaction of researcher and subject creates the possibility of going beyond the conventional stories… to reveal experience in less culturally edited form."(13) In the medical humanities classroom, oral histories provide aural texts with which students can engage in a different way than with written or cinematic texts. Oral history theory enriches our understanding of the dialogic encounter as a relationship building event, and the oral narrative as a co-created story reflecting both teller and listener. As a classroom methodology, oral history exercises allow learners to witness stories in profound and potentially transformative ways, even as they witness their own processes of witnessing. By placing the interviewer in the position of self-reflective learner, oral history suggests for clinicians a radically different stance from which to approach storytellers. Ultimately, these exercises can inspire not only a deeper understanding of the self and the other, but advocacy and action.

In the words of Marleise Brosnan, describing her own interview with Casey, "The interaction is central and what he is writing is secondary…He is having his say and I am the instrument that is giving voice to his thoughts. To my absolute surprise, I enjoyed the sound of my voice while listening to the tape afterward. I believe this is because although you can only hear my voice it is not really mine alone, it is ours. Our real time experience put both of us in the moment of his immediate thoughts and gave his voice meaning. It was a joyful experience."(14)

Endnotes


1. Frank, Arthur. The Wounded Storyteller: Body, lllness, and Ethics. Chicago: University of Chicago Press, 1995, p.xii.

2. Both the student and her interviewee kindly granted permission for their story to be shared here.

3. Bauby, Jean-Dominique. The Diving Bell and the Butterfly. New York: Vintage Books, 1997.

4. Both the student and her father kindly granted permission for their story to be shared here. Her comment here is complex and multilayered, she is both writing through Jean-Dominique Bauby’s story - adapting a quote from page 44 of his memoir - but Bauby and she are of course also referencing Susan Sontag’s notion from her Illness as Metaphor of illness and wellness as separate 'kingdoms.’

5. Frank, Ibid, p.37.

6. Both the student and her subject kindly granted permission for their story to be shared here.

7. Grele, R.J., "Directions for oral history in the United States," in D.K. Dunway and W.K. Baum (eds.) Oral History: An Interdisciplinary Anthology, Walnut Creek, Ca: Altamira Press, 1996, p.63.

8. Perks, R. and Thomson, A. (eds.), The Oral History Reader, NY, NY: Routledge, 1998, p.ix.

9. Portelli, A. "There’s always gonna be a line," in The Battle of Valle Giulia: Oral History and the Art of Dialogue, Madison, WI: University of Wisconsin Press, 1997, p.24

10. Portelli, A. Research as an experiment in equality. In The Death of Luigi Trastulli and Other Stories: Form and Meaning in Oral History. Albany: SUNY Press, 2001, 29-44.

11. DasGupta, Sayantani. Narrative humility. Lancet, 2008 March 22; 371 (9617):980-1.

12. After suffering locked-in syndrome secondary to a massive stroke, and being left with only the full use of his left eyelid, Bauby dictated his memoir to a scribe using a complicated system whereby she would say every letter of the French alphabet until he would blink. Bauby would memorize whole passages he wanted to write, then laboriously communicate them letter by letter.

13. Perks, R. and Thomson, A. (eds.), op cit.

14. Marleise and Casey graciously granted permission for their experience and words to be shared here, and indeed asked that their names be used.

A Medical Humanities Perspective On Racial Borderlands

June 30, 2008 at 10:31 am

Children of various skin colors and 14 DNA profiles in color

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

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

The events

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

What is race?

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

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

Race-based medicine

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

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

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

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

Categorizing race/ethnicity for medical humanities

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

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

References
1. Sandra Soo-Jin Lee, Joanna Mountain, and Barbara Koenig. The Meaning of Race in the New Genomics: Implications for Health Disparities Research. Yale Journal of Health Policy, Law, and Ethics. Spring, 2001, pp. 33-75.
http://www.yale.edu/yjhple/volume_1/pdf/033%20(koenig).pdf

2. Alexandra Shield, et al. The Use of "Race" Variables in Genetic Studies of Complex Traits and the Goal of Reducing Health Disparities. American Psychologist, Volume 60, Number 1, January 2005, pp. 77-103.
http://www.ncbi.nlm.nih.gov/pubmed/15641924

3. Troy Duster. Race and Reification in Science. Science, Volume 307, February 18, 2005, pp. 1050-1051.
http://raceandgenomics.ssrc.org/Duster/

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

Teaching Film: A Perspective From Narrative Medicine

June 13, 2008 at 9:32 am

Film Reels

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

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

A Topical Approach To Teaching The Doctor

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

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

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

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

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

A Narrative Medicine Approach To Teaching The Doctor

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

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

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

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

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

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

A facilitator might then pose the question:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Children of a Lesser God at Oxford

May 1, 2008 at 11:21 am

Actors performing 'Don Guzman' to an audience of deaf-mutes using sign language. Wood engraving by G. Durand, 1877.

Commentary by David Henderson Slater, M.D., Consultant in Neurological Disability and Rehabilitation Medicine, The Oxford Centre for Enablement, Oxford, England; and Laura May and Dora Steel, Class of 2010, University of Oxford Division of Medical Sciences

A faculty perspective: Why should medical students study literature, film, and the visual arts?

Why should doctors know about the arts? Is it just to have a rewarding interest away from a busy professional life? Or is it simply part of being a rounded personality, to be able to engage in enlightened conversation at a dinner party? Although there is a long tradition of doctors who have a ‘second career’ as artists, (Chekhov and Keats are obvious examples), in Britain medical training has become very scientifically driven. Medicine here is usually an undergraduate degree, often with an intermediate year of science leading to an additional Bachelors degree before qualification after a further three years. Few medical students have previously studied an arts subject to degree level (I had, but that is relatively rare). So most newly qualified doctors have had a very scientifically oriented training.

In the last few years in the UK there has been an increasing awareness of the value of the arts as a part of the formation of a rounded doctor. In some ways this represents a return to traditional values. Most entrants to medical school were traditionally from privileged sections of society, privately educated; a ’rounded’ student with a broad education, along the lines of the Corinthian ideal, could have been assumed. That has been less true in the last twenty or thirty years. And it has been observed that this lack of a sense of values and interpretations beyond the purely scientific is to the detriment of Medicine and its practitioners. As a consequence there has been increasing interest in making the undergraduate medical curriculum broader than a purely scientific training in Medicine. Whereas the old medical syllabus was tightly controlled and restricted, we now have optional modules as part of the undergraduate degree; these are known in Oxford as Special Study Modules. These last from four to six weeks. Students here choose them in their fourth and sixth year of study.

I work as a specialist doctor in a centre for people with life-long disabling conditions - at the Oxford Centre for Enablement (OCE), which is part of the Nuffield Orthopaedic Centre, one of the Oxford teaching hospitals. We have close links with both the University of Oxford and Oxford Brookes University. Our patients in OCE have a wide variety of chronic neurological conditions such as multiple sclerosis, motor neuron disease, stroke and brain injury, or have experienced major physical trauma resulting in amputation; they are often very immobile, and have a variety of cognitive impairments, emotional problems, pain, spasticity etcetera. We cover a large area of central southern England as a specialist tertiary referral centre. I run a Special Study Module for medical students from Oxford University who are in their fourth year of training (the course most of them follow in Oxford is six years long). The module (‘Models and Meanings’) attempts to combine study of the disabling conditions and the person’s experience of them with a study of the representation of illness and disability in the arts.

When we see a patient in clinic, or in the operating theatre, or on the ward, we see only a tiny part of their lives. We tend to see what they want to present to us. The clinic and the ward are not real life, or only a tiny part of it. If I really want to know what life is like for my patient I have to spend hours at it - perhaps also visiting them at home (something I often do) or in the Nursing Home. That way I get a feel for the things that get forgotten in clinic- such as the long hours of inactivity, or the financial poverty of the family, and an appreciation of what is important to them - for example the religious artefacts on the walls, the family pets, the old cars littering their garden, the half finished Do-it-Yourself projects. I had a young patient who was wheelchair -bound, and his grandfather was trying to make a shower room for him.A But the room never got finished - it filled up with the plumbing tools, and the debris of the family’s life, and he was left to fend for himself in increasing chaos. Seeing him in his room, cold and isolated, in a wheelchair most of the day, with no easy access to a bathroom, alone in the house for hours, taught me more about his life than any number of clinic appointments.

But sometimes we can’t access the patient in this direct way, and sometimes we don’t notice things. Our minds and our eyes need to be trained to spot things; so does our imagination. As trainee doctors we get extensive training in physical examination. I believe we also need to train our imagination, to learn to think what life is like for others, to experience things vicariously. When I was a medical student, I had never experienced a major bereavement. I read a book by C. S. Lewis, A Grief Observed, and I felt something of his grief, far more than from anything else I had experienced up to that point in my life. Literature and films can expose us to things we cannot otherwise experience.

However, what we see and read may be misleading. All art is selective from reality, and represents reality with a particular slant. In Britain, many people above the age of 50 will have a clear idea of what they think life as an amputee is like which is based on a film about a Second World War fighter pilot, Douglas Bader, whose exploits impressed the nation, led to his being knighted, and set a standard of achievement which is hard for real life amputees to match. Similarly the achievements of Para-Olympians and wheelchair athletes have set a standard infinitely beyond the hopes of most people suffering from significant impairments. The images on the TV screen show us the amputee who gets around the course, and are very unlikely also to show us the blistered stump, or the half-way-round drop out.

In the Special Study module for Oxford University medical students, I am encouraging students to think about representation, about the way we see things as doctors, the things we tend to notice, to comment upon (the thin abdomen, the scarring on the back of the leg), and perhaps also the things we tend to ignore or not notice - the red eyes of the patient’s wife sitting in the waiting room, the bewildered children playing with the clinic’s toys. We are trying to notice the ways in which disability and illness tend to be represented in the media (the ‘Plucky Fighter’, for example). We are trying to compare experience and representation - one of the current students is looking at the experience of amputees and comparing it with the representation of amputation in films, seeing what the patients themselves think about the way they are represented. In the last few days we have looked at a film which will be familiar to many because of its portrayal of the lives of a community of deaf students and their various hearing teachers. Children of a Lesser God has continued to cause controversy amongst non-hearing viewers over the years. Below are the observations of two medical students.

A medical student perspective: Disability and Children of a Lesser God

As medical students, we do get some teaching on disability as part of our training, but it is limited and always seen within the context of medical care rather than as a topic in its own right. The only window we have into most of our patients' lives is the time they spend in hospital, and it's easy to forget that many disabilities can have an impact on everything an individual does, not just their use of healthcare. As part of our training we are allowed to spend some time exploring subjects that particularly interest us, so we have taken the opportunity in this module to combine thinking about portrayal of disabilities in the arts with actually meeting people undergoing therapy at the Oxford Centre for Enablement. We watched Children of a Lesser God as part of an introduction to issues surrounding deafness, but also more generally to the problems that can arise in interactions between disabled and able-bodied people.

The film is set in the 1970s, when educational segregation based on disability was more common than today. Most of the action takes place in an isolated boarding school for deaf children on a remote island, and although the school is presented as a supportive and stimulating environment in which to learn, the expectations of the Headmaster for his pupils are limited - he seems entirely satisfied that Sarah, his star pupil, remains working on the island as a cleaner. Perhaps as a result, she is frightened by life outside the school community, which she has not experienced since childhood. This highlights the central dilemma of education for people with disabilities such as deafness: segregation within a supportive and specialised community, or integration into the wider world?

In Children of a Lesser God, segregation between 'hearing' and 'non-hearing' people is not just limited to the educational years. As exemplified by the adult lives of Sarah and Mr Leeds, deafness seems to divide the world into two opposite halves: those who can hear, and those who can't. This is portrayed as a sharp and definite distinction: perpetuated from outside the deaf community, as society segregates deaf from hearing; and from within it, as deaf characters such as Sarah and the children refer to 'hearing boys' or 'hearing girls.' Perhaps because it is drawn as such a sharp distinction, the interface between these two worlds becomes fraught with misunderstanding and assumptions, and this is exemplified in the romantic relationship between Sarah and Mr Leeds. Only at the end of the film, and after much hurt on both sides, is a point of compromise found. To what extent an impairment forms part of both an individual and a collective identity is an interesting question. It is a question complicated by the fact that one impairment is not equivalent to another, and that Deaf people may have a stronger sense of collective identity than, for example, people who have had amputations.

In describing these two communities, the film doesn't explicitly use loaded terms such as 'normal' and 'abnormal', but we perceive that on some level assumptions about what is normal and what is not are reflected in the behaviour of the key characters. Mr Leeds, young and handsome, arrives on the scene as something of a 'knight in shining armour', determined to improve the prospects of his pupils by teaching them to speak, rather than to sign. Although he is a flawed character, it is easy to identify with his enthusiastic altruism to 'help', particularly as doctors. Perhaps this is something we should be wary of; and find out what sort of interaction a patient may want with the healthcare profession before we try to 'get them back to normal.' Sarah's fierce opposition to Mr Leeds's attempts to teach her how to speak in the film are perhaps an extreme example of this, but it highlights the dangers of assuming too much, even with the best motives.

Ill-considered terminology, however, is far from the greatest threat which has historically faced disabled people from their able-bodied peers. The exploitation of disabled people is a familiar theme in the arts, and one which Children of a Lesser God explores: Sarah has been sexually exploited by her sister's hearing friends. Some disability activists criticise depictions of disabled people as victims, but sadly the frequency of such depictions probably reflects a reality in which abuse and neglect are common. Interestingly, this film also explores "exploitation" in another sense: Sarah exploits her deafness as a protection from the outside world. She is often demanding and gets away with more than a hearing woman would be able to, partly through using her deafness as a defence and as an excuse for unreasonable behaviour. There is ample explanation and excuse for this in her abusive background, but the point that disability may not be only a vulnerability but also a tool in social interaction remains.

Although the film explores many aspects of life as a deaf person and interactions between deaf and hearing people, one thing it struggles - understandably - to represent is the actual experience of deafness. It is as full as any other film of sound, music as well as dialogue - which, incidentally, is nearly always spoken as well as signed. Only in the swimming pool scenes, first when Sarah swims alone and later when Mr Leeds joins her under water, does the viewer experience complete silence. This is a remarkably effective device, and one that perhaps the film makers might have exploited more fully.

This commentary discusses Children of a Lesser God as a film about deafness, but that is far from all it is. First and foremost, it is a love-story, and also a story about coming of age and learning to see the world in a new way. Deafness is a central, but not the only, theme, and to treat a complex human story as a tract on deafness would be a reductive and limited view. Even if it were, it would be misguided to generalise from this film about disability in general; firstly, because not all disabilities are the same, and secondly because for many, deafness is not a disability at all.

______________________________

ACharacteristics of the patient described have been changed to prevent identification.

 

 

Medical Humanities: Sowing the Seeds in the Himalayan Country of Nepal

April 14, 2008 at 4:43 pm

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

Nepal, a country in the lap of the Himalayas is still predominantly agricultural. The majority of the festivals and cultural events have a strong correlation with the planting and harvesting of rice, the principal crop. With the hard rocky soil and the lack of suitable flat land it is difficult to cultivate crops in Nepal. Agriculture like in most of South Asia is a gamble dependent on the vagaries of that great seasonal phenomenon, the monsoon. Adequate rainfall at the right time is the major determiner of whether the sown crops will yield a good harvest and can mean the difference between eating well and going hungry. I was taking a similar kind of risk with an initial voluntary Medical Humanities module in the Himalayan country. Whether I would be successful at the end of the day depended on a variety of factors, the chief one being the enthusiasm and interest of the participants.

The PSG-FAIMER Institute

It was early January 2007 when I came to know about the PSG-FAIMER regional institute in Coimbatore, India through one of my good friends. PSG is a charitable group who run a number of educational institutions in Coimbatore, India and FAIMER is the US-based Foundation for the Advancement of International Medical Education and Research. The institute was inviting applications for a part-time fellowship in Medical Education and was inviting an outline of curriculum innovation projects from potential fellows. I have always been interested in medicine from a ‘different’ perspective. I have a keen interest in the history of medicine and am also interested in literature and creative writing. I am a keen trekker and photographer and have spent many weekends and vacations in the delightful trekking areas of Nepal. Most of my contemporary fellows (mainly from India) had chosen projects well within the confines of the curriculum. However, I wanted to do something that pulled together my interest in history, literature, and art within the framework of medicine, something along the lines of what is called Medical Humanities in the west." I discussed my proposed curricular innovation with Dr. SK Dham, dean of the Manipal College of Medical Sciences in Pokhara, Nepal, and he was very supportive. I decided to submit my project and hope for the best.

The first on-site session

It was a delightful experience to receive the e-mail from the institute confirming my selection. The first on-site session was to be held in mid-April at Coimbatore and I set about working on the project. At Coimbatore we were taught about project planning, force-field analysis, concept maps and looking at the project in a structured fashion under various headings. The overall attitude towards my slightly novel project was positive though there were occasional suggestions to choose a more conventional subject. The food at Coimbatore was a delight and I could not have enough of idlis, dosas, upma and other South Indian delicacies.

Initial days of the project

On coming back to Pokhara I started work on my project in earnest. The first task was to obtain feedback from the stakeholders and design a curriculum. One of our faculty members at PSGFAIMER was Dr. Janet Grant of the Open University, United Kingdom and she was kind enough to send me material on curriculum design. For a long time I had been intrigued by a feature in the journal Academic Medicine titled ‘Medicine and the Arts’ (MATA). I wanted to contribute and wrote to Ms. Anne Farmakidis who was in charge of MATA at that time about how I should go about writing a MATA article. She gave me a few hints and was kind enough to send me a copy of the book titled Ten Years of Medicine and the Arts. The book’s a compilation of MATA articles published over the years from 1991 to 2001. The book was a delight to read and I was hooked! This book was also a key factor in strengthening my interest in the medical humanities.

Preparing for the module

The module I was planning was voluntary so maintaining participant interest was the key! I had noted that in many courses of study in South Asia the objectives are not clear. I resolved to put down the objectives of each session on paper in black and white. Ironically I ended up with clearer objectives for a ‘soft’ course like Medical Humanities than for courses like Anatomy or Pharmacology! I also set about constructing a student guide, a facilitators’ guide, a guide to further reading, and session descriptions. A major question in my mind was how many sessions should be conducted. I wanted the module to serve as an introduction to the fascinating topic of medical humanities. As part of the course I was in touch with my friends and faculty at the PSGFAIMER Institute through a listserv and we started discussing how to go about our respective projects. We also cover various topics related to health sciences education every month. As medical humanities is not well developed in South Asia I got in touch with various medical humanities educators from other regions through e-mail. All were gracious enough to respond and offer their suggestions. All wanted to help kick start medical humanities in a developing Asian country. I owe a special debt of gratitude to Dr. Johanna Shapiro of the University of California at Irvine, Dr. T. Jock Murray of the Dalhousie University Faculty of Medicine, Canada and Dr. Tom Tomlinson of the Michigan State University in US. My friend, Dr. Rakesh Biswas was also very helpful.

Learning modalities

I finally decided to conduct fifteen sessions divided into three units titled Medicine and the Arts, Ethics and Medicine, and Contemporary Issues in Medicine. There were also home assignments. A major goal of the module was to make learning fun and avoid the heavy, boring didactic teaching which is in vogue in most of South Asia. Learning sessions were to be conducted in small groups and were to be activity based and interactive. Literature and art excerpts, role plays, case scenarios were among the different modalities used to explore various aspects of the humanities. Medical humanities was not widely known and it was up to me to popularize the term and what it meant. MCOMS has two campuses with the basic science campus being located at the scenic and wooded Deep Heights in Pokhara. The students run a wall magazine called Vibes and I often contribute to this delightful magazine. (A wall magazine is like a notice board and various articles and features are put up on the board. The contents are changed regularly and a particular collection of articles and features constitutes an issue.) I wrote an article about medical humanities for Vibes.

Sources of literature & art

For the module I mainly used literature and art excerpts from a western context. I was able to use a couple of excerpts from South Asian authors in the module. Photos of the violent conflict in Nepal were used and the majority of the participants could easily relate to this. A major difference between America and Nepal is that in Nepal, like in most of South Asia the student-teacher relationship is authoritarian and hierarchical. I had to make sustained efforts to get the students to open up. The case scenarios and role-plays were designed by me to reflect various aspects of the practice of medicine in Nepal and south Asia and were well received by the participants.

Canvassing for volunteers

I started canvassing support among the students of the clinical semesters. In Nepal the undergraduate medical course is of four and half year duration and is divided into nine semesters. The first four semesters are devoted to the basic science subjects and the last five to the clinical ones. Initially I concentrated on the fifth semester as the students had just entered the clinical phase and were the most ‘free’ batch of learners. However, the fifth semester also runs a program to help the poor patients of the hospital — the socially aware and active students were active in the poor patients’ fund and had no time for medical humanities. I then turned my attention towards the sixth semester. I started canvassing among faculty members to join. My colleague, Subish is keenly interested in the more rational use of medicines and other issues as well; he enthusiastically participated in the module. He was instrumental in providing the excellent facilities of the Drug Information Center Conference room for the sessions. The room helped to create a relaxed, protected and comfortable atmosphere.

Initial days of the module

The initial sessions were a touch and go affair. People kept coming to the sessions and dropping out. Some of them were irregular in attendance, attending scattered sessions. Gradually word spread about the unique module. Participants started coming and staying! A sixth semester student came to test the waters; she found it was to her liking and more of her friends joined. One of my colleagues, a physiologist, trekker, artist, photographer and many other things besides was an enthusiastic participant. My clinician friends were generous in sharing their rich clinical experience as co-facilitators. Another colleague had done his doctorate in Denmark, where, as in most of Europe, it is expected that medical and other health science students know some philosophy. With his help I started a ten minute discussion on philosophy during the module. One of my students then in the final year of medical school asked me to contribute an article about medical humanities for the college magazine, Reflections which they bring out.

Sessions for the Basic Sciences

The students in the Basic Science campus requested me to conduct a module for them. It was difficult to find a time period convenient to both the parties and finally we settled on the lunch break. It was indeed gratifying to note the enthusiasm of the participants. This module was conducted along the same lines but each session was divided into ‘bytes’ spread over three working days.

Novelties of the module

The module introduced a few new concepts and also further developed certain others which I had been using in my small group sessions for students. Constructive formative assessment, reflective writing assignments, assessment of the facilitator and faculty and students learning together were a few of them.

Module at KIST Medical College

At present I am conducting a module for faculty members at the KIST Medical College and these members could be used as co-facilitators for future sessions. I really enjoyed being a part of Humanities 101 and I am sure my student and faculty participants did too. I sincerely hope the seed of medical humanities will take root in the fertile soil of Nepal (among the highest countries on Earth) and bloom among young, energetic and impressionable minds!

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

March 13, 2008 at 10:46 am

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

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

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

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

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

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

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

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

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

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

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

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

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

What Is Medical Humanities and Why?

January 25, 2008 at 11:25 am

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

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

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

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

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

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

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

Medical Ethics on Stage

January 11, 2008 at 3:33 pm

Actors performing 'Don Guzman' to an audience of deaf-mutes using sign language. Wood engraving by G. Durand, 1877.

Commentary by Angela Belli, Ph.D. Professor of English, St. John's University, New York City

For those interested in the debates concerning ethical issues in biomedical science and technology, the domain to visit is the theater. Playwrights frequently focus on the conflict between human values and the rapidly changing technology that has come to prevail in the delivery of health care. They find in contemporary medicine a rich source of material. Current theatrical representations of medical discourse take their authority, language, images, and charactersaa whole roster of professionalsaall from medicine. A quick perusal of some of the most honored plays of our time reveals how the dramatic conflict, essential to the structure of the work, may be located in an ethical issue to gain the dramatist's attention.

End-of-life issues, including the termination of treatment, are presented in graphic terms in Brian Clark's Whose Life Is It Anyway? The question posed in the title is examined from three perspectives: medical, philosophical, and legal. The protagonist, Ken Harrison, is a hopelessly paralyzed young sculptor who is kept alive by mechanical means. Feeling that he has lost all personal and artistic freedom, he concludes that to continue him in such a state is to deny that which distinguishes him as a person. He is opposed by his attending physician who believes that if he allows Ken to die he will be aiding him in an act of suicide. The play turns on one issue: the goal of medical ethics. The resolution confirms the view that if a goal of medical ethics is the restoration of health and if therapy is inadequate to restore those functions that enable one to pursue one's spiritual goals, then medicine need not assume an aggressive role.

The Elephant Man by Bernard Pomerance presents a study of the need to uphold human dignity. Set in the Victorian Age, the play recalls the life of John Merrick, an actual individual who suffered from what is represented as neurofibromatosis. Severely disfigured he is shunned by society and regarded as a freak. Another view, "the medical gaze," is introduced when Merrick's condition comes to the attention of an idealistic young surgeon, Frederick Treves. Aware of the limitations of science to restore his patient to health, Treves undertakes a project in behavioral research, reconstructing a social context for Merrick. The play reaches its climax when the patient realizes that the life of normalcy and freedom created for him are illusory. Merrick's final triumph lies in his successful act to repossess the dignity he had been denied.

Margaret Edson's play W;T introduces a heroine whom the audience views during the last two hours of her life passed in a research hospital where she has been a participant in an experimental chemotherapy program. Issues regarding the treatment of the individual as research object give rise to the dramatic conflict, with the heroine confronting various staff members who are anxious to keep her alive for research purposes. In the conclusion of the drama, she regains mastery of her fate and her human will as she overrules the orders of the medical staff with a directive of her ownaher DNR request.

Another heroine who leads us to confront challenging ethical questions appears in Mark Medoff's Children of a Lesser God. The dramatic focus is on a young woman who has been deaf since birth. Questioning the attitudinal barriers erected by the social majority who fail to communicate with the afflicted and, consequently, conclude that the deaf are mentally inferior, she resists being marginalized and demoralized. Moreover, she insists on using sign language, her preferred means of communication. Choosing her own means of expression is essential to preserving her integrity. Along with the social model, the medical model is recognized in the play. Medicine's assessment considers the disability to be an illness requiring treatment. A form of intervention such as cochlear implants is frequently advocated. Ethical issues emerge as the varying views of disability give rise to the dramatic conflict.

In his brief, one-act drama The Sandbox, Edward Albee examines ageism, a pervasive canker in the social fabric that targets older individuals. The dramatist locates the bias within American society and spotlights the family structure as a likely site. Further, he examines the stereotype that links ageing with cognitive decline and leads to the erroneous conclusion that the elderly are of little value.

Michael Cristofer's The Shadow Box offers an artistic view of the philosophy of hospice care, which provides dying patients with an alternative to traditional, impersonal care provided by the established medical system. On stage the dramatist presents an assortment of patients, friends, and family who are torn between accepting a life that has been altered irrevocably for each or disallowing the reality they cannot escape. The drama reveals the value in affirming life and embracing the quality of the time that remains.

The dimensions and cultural ramifications of HIV/AIDS share galvanized discourses within medical, political, and artistic spheres. The theater provides its own sanctuary within which the public may consider the effects of a baffling disease that has shaken the security and confidence in biomedical advances. While constructing an illusory world, drama locates the dialogue in public space, providing a unique opportunity within a communal setting for raising awareness as it promulgates the facts and spurs socio/political action. One play to achieve such goals is Before It Hits Home by Cheryl West. The work recounts the dissolution of an African American family as it reacts to the unexpected crisis in its midst when a son is revealed to be infected.

In searching for valuable tools to encourage greater understanding and knowledge of bioethical dilemmas, one may consider placing copies of some good plays on the desks of medical students, alongside classical texts on medical ethics.

Note: All plays referred to above, except Children of a Lesser God, will appear in the forthcoming (2008) anthology, Bodies and Barriers: Dramas of Dis-Ease, edited by Angela Belli and part of the Literature and Medicine series at The Kent State University Press.

Further Reflections on Medical Humanities

December 22, 2007 at 3:32 pm

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

 

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

Medical Humanities: Education or Entertainment?

November 8, 2007 at 4:46 pm

Medical Humanities: Education or Entertainment?

Commentary by Brian Dolan, Ph.D., Professor of Social Medicine and Medical Humanities at University of California at San Francisco

A few weeks ago, I hosted a workshop for faculty from a number of campuses who work within medical centers and are involved with medical humanities courses or programs. My opinion at that time was that scholarship and courses in the medical humanities needed to be academically rigorous to gain credibility amongst medical educators who are obsessed with defining skill sets, setting objectives, and measuring the "impact" of course content. I was (and am) not prejudging anyone's commitment to academic standards. But if anyone had experience anywhere close to my own, it probably involved meeting with skepticism from within medical centers about the uses, or "value added," of providing instruction in medical humanities in an already overcrowded curriculum. Fundamentally the challenge of maintaining a role for medical humanities seems to lie in balancing the students' desires for freedom of intellectual inquiry with an institutional pressure to herd.

I asked others what kinds of projects are supported under the name of medical humanities in their institutions. Does a jazz session count? Painting? Poetry writing is very popular amongst students, residents and faculty, but why, I wondered, can't that just be called a hobby? On the other hand, we have an "art for recovery" program, and it raises provocative questions and potential data about the importance of humanities-based therapeutic intervention for patient care. Thinking I was playing devil's advocate, I asked why all this had to be brought further into the classroom and formalized, naming specific skills and objectives to be met through such instruction? Might that raise further problems rather than provide increased opportunities for the students? What follows is a paraphrasing of my thoughts and discussions about this.

Would medical students want to pursue course work laden with the requirements that match the rigor and standards set for students geared for a different degree path? Why not, I thought. When I was in college I took electives to see what other fields were all about and I didn't expect to be given a watered-down version. It would be offensive to humanities scholars to ask them to present their subject in a different way to medical students. Esteemed colleagues of mine who hold MDs and teach courses in writing believe in the rigor of course workathey themselves have enrolled in humanities courses and on occasion received other degrees. On the other hand, I repeatedly hear that medical students don't read, so don't assign too much. And is going into Foucault's notion of the "clinical gaze" really necessary? Is there utility in making medical students genuflect to the humanist-theorists in the way that professional humanists need to do for career advancement?

But who said anything about professional humanists (i.e., people with PhDs in history, literature, philosophy, etc.)? I have also been told that medical students will not really pay attention unless the instructor has a MD. They need role models, leaders who will show them that it is OK for MDs to pursue such interests. Also, unless you have been in the clinic, it's hard to share the emotional reasons why humanities are useful. It sounds like it's therapy, I say, a different kind of utility than opening up new research methodologies for reflecting on the complexities of modern medicine. It then struck me that the distinction between "education" or "entertainment" is not absolute but relative to what one wants out of it. The humanities can represent deeply philosophical, pragmatic, emotionally driven and/or entertaining approaches to understanding the human condition and the social relations of physicians, scientists, patients and the rest of the world.

The dilemma of medical humanities is not that it is reduced to a formulaic set of educational goals or dismissed as a form of entertainment, but that it is a "field" with no boundaries, yet apparently centered on each individual. To think and act like a humanist-physician or humanist-scholar requires an understanding of one's relationship to the rest of the world. Whether one is analytical in approach or expressive, a chronicler of the times or a jazz musician, the humanities supports your form of engagement. It seems counterproductive to reduce this to skill sets and the mechanics of cognition. "The medical humanities" is a form of consciousness about all that is educational and entertaining about being human. It embraces what should be the overwhelming commitment of every medical school: to honor art and humanism in medicine, however that is expressed, and by whomever it is expressed. The lesson of medical humanities ultimately relates to respect for others' views, but formalizing that runs the risk of excluding people from that lesson-plan. My feeling now is that medical humanities should not be curricular-bound; it is too big for that. Rather, it should be articulated and supported as part of campus culture, contributed to by everyone who thinks of themselves as a humanist. This does not exclude instruction or "education," but neither does it dismiss "entertainment." In fact, make the elective or non-credit classes entertaining. After all, that might be more important than subjecting students to another test.