Commentary by Allan Peterkin, MD., Associate Professor of Psychiatry and Family Medicine, University of Toronto; Head of The Program in Narrative and Healthcare Humanities; founding editor, ARS MEDICA: A Journal of Medicine, The Arts and Humanities

Most medical schools in North America have Bioethics divisions but not all have humanities programs. In the current climate of funding cutbacks and loss of investments for establishing new university Chairs, many academics assume that they will never have the resources to develop a new humanities program for their students in healthcare.A In this essay educators are encouraged to move forward all the same. By growing a grass-roots program and building a vibrant humanities community on their campus, they can have impact on the culture of learning at their institution and become a vital resource for their university. Administrators may then be persuaded to pay heed to the results and to offer administrative, institutional and financial support. Here are fifteen steps that were employed at the University of Toronto medical school and led to the granting of official status to the author's program and to pledges of funding from multiple sources.

1) Start with a hospital-based initiative and make sure colleagues and administrators know about your work. Hold monthly, inter-disciplinary lunchtime meetings with engaging speakers tackling "out of the box" subject matter. We've had sessions given by a family doctor studying to be a professional buffo clown, a toxicologist discussing poisons in opera, a nurse-dancer addressing the need for movement for children in hospital and how that might impact hospital design and a social worker offering `on the spot Atraining` for mindfulness in the hospital setting. Cast a broad net. Invite students and faculty from both health and arts disciplines. Advertise events in your university newspaper and hospital bulletin. Serve snacks (if you can!) Ask participants to fill out evaluations of the sessions . Keep these in orderAto demonstrate impact and for fine-tune your programming.

2) Choose a name for your program and be inclusive. We called our initiative "The Program in Narrative and Healthcare Humanities" in order to have appeal across disciplines. Some non-physician colleagues and other clinicians may object to (or feel excluded by) a "medical" humanities nomenclature.

3) Consider starting a newsletter, blog or print/online journal. We started "ARS Medica: A Journal of Medicine, The Arts and Humanities" 5 years ago with a small start-up fund from our very supportive Department Head and established a voluntary editorial board. The journal was/is a labor of love and has become the voice of our emerging discipline. Government arts grants have followed and the journal hit the radar of the university administration when we introduced a study guide with questions for reflection and study. The journal is now offered free of charge to all first year medical students in an innovative pilot research initiative.

4) Form partnerships with non-medical colleagues. Contact the heads of the English, History, Philosophy and Film Studies Departments and invite them and their colleagues/students to your monthly meetings. Find out who has a particular interest in health/disability/illness/narrative studies and ask them to present or to be a discussant.

5) Form partnerships with other healthcare humanities organizations nationally and internationally to obtain further guidance in establishing your local program. Join list-serves. (For example both the NYU Literature, Arts, and Medicine Database and the Literature and Medicine affinity group of the American Society of Bioethics and Humanities have been extremely helpful in assisting us to choose literary content for teaching students and for canvassing what's being done in the field.)

6) Form writing and research alliances with local, national and international colleagues. Publications and presentations are hard to ignore by funders and Deans.

7) Infuse your own department/faculty with humanities projects and seize opportunities to introduce arts-based content into existing curricula and lecture content. Ask to give a Grand Rounds on an art-based theme. Organize a student art exhibit in the lobby of your hospital or a yearly humanities essay contest. Introduce a poem or short text into morning rounds and link it to the subject matter or diagnosis at hand. Submit a workshop to a faculty development/ CME conference. (We offered three narrative-based medicine workshops to the Department of Family Medicine which were highly rated and subsequently increased the demand for training on reflection which incorporated writing and reading tasks). Make sure your offerings appear on your Departmental and Hospital websites.

8.) Form a list-serve and build a virtual humanities community for students and faculty. You'll discover that many of your colleagues (including those in non-clinical fields like research) are using arts-based teaching innovations but believe that they are working in complete isolation. They will be delighted to find like-minded educators and scholars at their own university and will also support future, more formal initiatives and funding requests. Build a website outlining the history of your program, listing affiliated faculty and summarizing presentations, initiatives and publications. Provide links to other healthcare humanities websites and organizations and ask to be listed on their websites as well. Post narratives and educational resources (like lists of films/texts useful in teaching). Become a "Go To" resource for colleagues in curriculum design and interprofessional learning.

9) As you build links with colleagues, prepare a list of possible electives which can be offered to students and residents. We have offered electives in guided reading on specific topics, creative writing and editing (working with Ars Medica editors) and have facilitated links with non-medical faculties. Make sure these electives meet the standards of your school and ensure that they are included on your website and in the syllabi of offerings for students and residents. Keep evaluations as evidence of your impact.

10) Hold evening events in the homes of your humanities faculty several times per year. A movie night for students and residents works well, as does the showing of episodes of specific TV series such as House or Nurse Jackie. Allow trainees to suggest content or to be a discussant.ASuch meetings build morale, foster community and help to advertise your other initiatives. Attendees may then volunteer to help you with specific tasks related to your program-building (publicity, research, writing letters of support etc.)

11) Organize an annual or bi-annual conference on a health humanities- based theme and hold it on campus. Last year we paired up with colleagues from the Department of English and offered a multi-disciplinary, international colloquium called Narrative Matters. One of our speakers was Dr Rita Charon, founder of the Narrative Medicine Program at Columbia University. Our Deputy Dean of the medical school was more than happy to introduce Dr Charon, but also took notice of the breadth of our initiative.

12) Offer to consult to your faculty on developing the potential links between the humanities and faculty wellbeing, professionalism, reflective capacity and interprofessionalism. Prepare/post resources of readings, films, writing exercises and websites which may be useful in teaching, personal learning or research. By offering our services, we were able to create 2 new courses on reflection and writing and to produce a humanities reader for first year medical students. We built the case that humanities-based initiatives needn't "steal" or compete with precious lecture time, but can be introduced organically at all levels of training from the pre-clinical years to Continuing Medical Education initiatives.

13) Hone your qualitative research skills and link with local, interested consultants. The impact of most humanities-based initiatives cannot be captured by standard bio-medical research protocols. Nonetheless your Dean will likely request proof for the relevance of your work, its impact on learning and for publications in peer-reviewed journals.

14) Act like an official program until you become one.AForm an official working group/program development committee. Keep minutes of your meetings. Prepare an annual report and then request to share it with/present it to your hospital Chief, Departmental Chair, Dean and other educational Deans at your faculty.

15) Choose your moment to request more official status (ie to be identified as a University program/resource rather than a local, hospital or specialty-based one) Be aware of trends in curriculum development within your Faculty (ie the introduction of a new portfolio for teaching, increasing demand for narrative-based interprofessionalAseminars.) as these may offer opportunities for enhancing the profile of your work. List affiliations/partnerships with other departments at your school to show that you have the support of key players on campus. Prepare a three year budget. Your start-up year should be at least 20% more than years two and three. Prepare a dream list for future development. (We hope to have a writer in residence and a fully endowed Chair at our university within 5 years). Explore all funding options including existing competitions for innovation in course design or inter-professional teaching. Your Dean may be more willing to match funds from your department, hospital or outside sources, rather than to fund your program in its entirety.

Readers of this blog are invited to share practical strategies of what has been successful (or less so) in their own settings. Let the dialogue begin!

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

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

The voluntary module at Pokhara

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

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

Sessions for basic science students at Pokhara

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

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

Sessions for clinical students at Pokhara

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

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

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

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

Module for faculty members at KISTMC

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

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

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

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

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

Module for students at KISTMC

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

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

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

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

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

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

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

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

Commentary by Daniel Goldberg, J.D., Ph.D. Health Policy & Ethics Fellow, Chronic Disease Prevention & Control Research Center, Department of Medicine, Baylor College of Medicine; Research Faculty, Initiative on Neuroscience & Law, Department of Neuroscience, Baylor College of Medicine

There is a legal doctrine known as "attractive nuisance." The basic idea of the concept, grounded in the law of torts, is that an owner or occupier of a premises can be held liable for negligence if they are responsible for a dangerous condition which is reasonably likely to attract vulnerable persons, such as children. Sometimes the medical humanities are for me akin to an attractive nuisance inasmuch as I tend to be easily distractible and scatter-brained, and thus can wallow in to deep pools before I realize I am well out of my "safe" zone.

Of course, practicing the medical humanities is not a nuisance at all; it is a privilege to be practicing, instead of merely rhapsodizing about the merits of, an interdisciplinary approach to health, illness, and medicine in society. But the privilege comes with significant danger as well, and I have of late become more impressed with the need to focus in on a few key areas which I hope to make part of my comfort zone. One of these areas of interest is disease causality.

Causation

Causation is one of those fecund topics whose enormous importance seems to surpass disciplines. A favored subject of antiquity, it remained central to Thomas Aquinas, Maimonides, and many of the other medieval scholars, to the early modern greats like David Hume and Immanuel Kant, and remains a critical subject in contemporary philosophy of science. Kant, whose epistemology is in my view often shamefully relegated to the background of his moral philosophy, was convinced that causation is a category of understanding, such that we cannot make sense of the phenomenal world without the concept.

But not only philosophers treat of the importance of causation, especially in context of medicine and illness. Medical anthropologists, for example, have long since pointed out that comprehending how a given community understands disease causality provides critical insight into the meaning of illness, suffering, life, and death. Anne Fadiman's well-used book, The Spirit Catches You and You Fall Down [1], is a nice instrument for teaching this point, as it seems inescapable that greater understanding (if not acceptance) of the Lee family's beliefs about Lia's illness experience would have greatly improved the family's medical experience.

As a self-identifying public health ethicist, my particular focus right now in thinking about disease causality is in the context of stigma. The history of stigma in context of illness can, to my mind, be traced back virtually as far as one wishes in Western civilization. (I believe it is reasonably prevalent in non-Western cultures as well, though I admit to a shameful level of ignorance on the specifics here). The reasons why stigma is so common in illness scenarios are multi-faceted, complex, and in my view have powerful explanatory capacity in conceptualizing health, illness, and disability. Fortunately for the able readers, as I have some work in review on the subject, I shall not be discussing it here (though some general thoughts on the subject are available on Medical Humanities Blog.

Disease Causality and Stigma: The Case of Fatness

What I want to suggest here are the connections between a particular notion of disease causality and stigma. One of the most obvious examples is the relationship between fatness and illness. As Gard and Wright [2] painstakingly documented in their fabulous 2005 book, the connections between fatness and disease are typically taken to be virtually certain among both lay and professional communities. And what are the consequences? That is, what results if we assert that type II diabetes, coronary artery disease, and cardiovascular disease, among others, are caused by fatness?

Of course, responding to the question of "what causes diabetes" by answering "fatness" is really a set of additional questions masquerading as an answer. Many of these questions turn on the differences between causes and risk factors, but to approach the issue of stigma, one must ask what causes fatness? (Naturally, to even speak of singular causes of intricate, nonlinear systems like disease in populations is absurdly oversimplified; one of the problems with causal attributions of illness in both lay and professional discourse is our general reduction of these complex systems to single, discrete variables. This is of course a hallmark of the Western scientific method, and the history of how we came to do so is, I think, quite important. But that is another post altogether.)

Life-style Model of Disease

In any case, what causes fatness? The usual answer turns on some fairly innocuous-sounding mishmash of genetics and environment, but the so-called model of disease causality here is often referred to as the "lifestyle" model. And lifestyle-type thinking is, particularly in American culture, deeply ingrained with notions of choice. We choose whether to pursue this lifestyle or that one; and so, in a very real sense, we choose whether to be fat. If fatness causes illness, it follows that we choose whether to be sick (with diabetes, coronary artery disease, etc.). This is in part why breathless reports of genetic linkages with fatness incite so much controversy - one of the perceived implications of such linkages is that individuals are not responsible for their fatness.

Of course, as I have noted on Medical Humanities Blog (see "On the Genetics of Jewishness"" and "On Genes & Diabetes Disparities", our discourses of genetic causation are problematic in a great number of ways, not least of which is the notion that "genes" actually cause anything at all in a linear sense. Genes do have causal effects, of course, but those causal effects are only produced through a complex system in which social, economic, cultural, and environmental factors profoundly shape expression. As Jeremy Freese has noted, the idea that the causality of an illness can be divvied up into x% - genes and 1-x% - environment is deeply mistaken [3]. Thus mere genetic linkages themselves are, from a causal perspective, not very interesting separate and apart from the inordinately complex systems through which they express (or do not).

Critique

One of the most compelling criticisms of the lifestyle model of disease is not that it is false; but rather, it is incomplete inasmuch as it pays no attention to the ways in which social and economic conditions substantially determine one's lifestyle choices. Even if we were to grant the exceedingly dubious proposition that fatness causes diabetes, drilling the causation down to individual lifestyle choices ignores, in my and many others' views, the robust evidence that lifestyles are primarily the product of social and economic conditions (the social determinants of health).

And of course, our model of disease causality is frequently embodied in how we regulate behaviors thought to cause illness. If one sees society as what Robert Jay Lifton termed a "biocracy" [4] as prevailed in the early 20th century in both Europe and the U.S., then the solution to the inherited "degenerate" behavior that produced diseases like insanity, mental retardation, and syphilis was to enact laws which precluded such inheritance. Alternatively, one could also support laws that precluded the "amalgamation" of "racial stocks" in which such degeneracy proliferated.

Similarly, if the cause of diabetes and CAD is perceived to be fatness, and the causes of fatness are unhealthy lifestyles, the perceived public health solution is to regulate such lifestyles, by, for example, strictly regulating the food available in school cafeterias, or requiring restaurants to print calorie information on their menus and web sites. In contrast, if the cause of fatness is perceived to be social and economic conditions, policy solutions would seem to fall much closer to ameliorating the conditions which seem to promote unhealthy lifestyles. (I hasten to remind readers that I am quite skeptical of the causal links between fatness and illness, but I assumed the validity of the attribution to take the point further).

In any case, disease causality is an important, and, in my view, understudied concept in the medical humanities, one that ties in quite deeply to notions of stigma, disability, and moral culpability for illness.

References
1. Anne Fadiman. The Spirit Catches You and You Fall Down (New York: Farrar, Straus & Giroux, 1997).
2. Michael Gard and Jan Wright. The Obesity Epidemic: Science, Morality, and Ideology (New York: Routledge, 2005).
3. Jeremy Freese. "The Analysis of Variance and the Social Complexities of Genetic Causation," International Journal of Epidemiology 35, no. 3 (2004): 534-36.
4. Robert Jay Lifton. The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 2000).

Commentary by Michael Nevins, M.D., author of Jewish Medicine: What it is and Why it Matters and A Tale of Two "Villages": Vineland and Skillman, NJ. This commentary written in conjunction with an exhibit at New York University School of Medicine, Sept. 24-Oct.19: Art and Medicine in Terezin.

All of us felt a sense of sliding helplessness, again and again, day after day, night after night, you descended toward the abyss whose bottom was unfathomable….you felt only the downward movement, the fear, what next?

These chilling words, reminiscent of an earlier Prague resident Franz Kafka, were written in April, 1942 by Bohemian dermatologist Karel Fleischmann. With the Nazi takeover of Czechoslovakia in 1939 the situation for Jews had deteriorated and anti-Semitic racial laws restricted the doctor's ability to practice. Now at age forty-five, Dr. Fleischmann (b. 1897) awaited deportation to Terezin, the recently established ghetto town some forty miles to the north.

The morning of our deportation was pitilessly cold. The clouds as black as ink, the rising sun blood red in the background…darkness on earth, darkness in our souls…a nightmare. We arrived in Terezin in the evening. Really, you did not arrive, you were consigned. Someone managed for us for we no longer were we - we had become an object, a number, a ground substance, a kneaded mix of humans….Tired to the bones, sick, longing for quiet and sleep, we came into the cellars and dark holes of the barrack…still the mass was mixed, kicked and reduced to nothing, dirtied, put on the floor, kneaded and rolled till we became a formless porridge, a heap of rubbish….poisoned with the taste of the stable.

Dr. Fleischmann had been advised that upon arrival in Terezin he should look up the head of the ghetto's Health Department Dr. Erich Munk, but making contact was difficult. Known for his scrupulous integrity and organizational ability, the thirty-eight year old radiologist Munk (b. 1904) had been selected by Zionist leaders to direct what would become a massive medical apparatus.

Whereas Karel Fleischmann was prolific with more than a thousand of his diary notes, poems and art work surviving the war, only a few fragments of Dr. Munk's words remain. The following probably written during his first year at Terezin describes his first unpleasant impressions:

We had not yet freed ourselves from the needs of comfort, social norms, social stratas, prejudices…We had not yet realized that we have been set apart for an unknown length of time into an uncertain future. The impressions are as damp as the weather had been. Muddy like the mood of us all. Was I desperate? No. I was only deeply touched. I needed two nights and two days to overcome my deep depression, to be able to overcome my own self. I was unable to concentrate my thoughts on work….It was at noon of the third day that I suddenly succeeded in breaking through and submerged myself straight into work. Work saved me…ever since then I haven't stopped working.

As they endured their personal metamorphoses, Drs.Fleischmann and Munk learned a crucial survival technique - they could help themselves best by helping others.

Terezin

In 1780 Emperor Franz Josef, the emperor of Austria, built a garrison town in Bohemia which he named Theresienstadt - the city of Theresa, after his mother Queen Maria Theresa. After the formation of Czechoslovakia in 1918 the town was called in Czech Terezin. Then with German occupation during World War II, again it was officially designated as Theresienstadt. In later years both names were used depending upon the perspective of the speaker or writer. English language references tend to prefer the shorter Czech version which is used in this essay.

The Terezin ghetto was euphemistically described by the Nazis as "a city of refuge" or sometimes as "Hitler's gift to the Jews." In truth it was an assemblage camp where Jews were concentrated for varying periods until they were deported to "the East" - another euphemism for death camps, particularly Auschwitz-Birkenau. At first,Terezin was intended for Czech Jews but, before long others mainly from central Europe were shipped there - affluent, privileged, older people — rabbis, scientists, war veterans, musicians, artists — as many as 58,491 in September, 1942, all sharing space with rats, lice and fleas. Few of them suspected what lay ahead; many felt fortunate to be in this safe haven - some even paid for the privilege. Famously, in June, 1944, a delegation from the International Red Cross visited and couldn't, or wouldn't, appreciate the masquerade. They reported favorably to the world on conditions in what Nazi called the "model city" — in truth it was a Potemkin's Village - a place of false facades.

Terezin is often remembered as the concentration camp where guards turned a blind eye to cultural activities that were put on by the prisoners. Perhaps these were permitted for the purpose of propaganda or to temporarily appease the doomed inmates. There was a cabaret of sorts with a jazz band and performances of Verdi's Requiem and the children's opera Brundibar were sung by doomed choruses. Hundreds of lectures were given by famous scholars. Why did they do it? For some it may have been an escape into a semblance of normalcy; for others it represented a proud act of defiance - of being able to act human in the midst of depravity. Yet, few prisoners actually could attend the cultural events - most were too exhausted from work or were literally starving. Although technically Terezin was not a death camp, between November 1941 and May 1945 of nearly 160,000 people sent there, some 36,000 died of illness or starvation; the rest, about 88,000, were deported to extermination or work camps with only a few thousand of these surviving the ordeal. When the Russians liberated Terezin in May 1945, there were only about 30,000 survivors, more dead than alive. Within weeks many more died of a typhus epidemic. Of more than 12,000 children who passed through Terezin, only 325 survived.

Health Care in the Ghetto

Terezin's main hospital was located in a large barrack which had been built in 1780 to service military and civilian populations of about 7,000 people. It was ill-suited to care for the needs of 40 or 50,000 prisoners at a time and although solidly built with high vaulted wards and a huge attic, it was a hospital with no beds or bandages, no sterilizing equipment or instruments. Nevertheless, there was an abundance of knowledge and resourcefulness among the physicians. Dr. Munk's Health Department was able to collect some antiquated or broken equipment; glasses, orthopedic shoes and trusses were fitted and repaired, test tubes were manufactured and eventually a central pharmacy was stocked from medicines confiscated from new arrivals. Later this was supplemented by supplies brought in from the defunct Jewish hospitals and clinics of Europe. And so, gradually, a semblance of a functional hospital emerged.

Fleischmann's Portrait of Dr. Munk

Concerning his art work at Terezin, Dr. Fleischmann once wrote "I wanted to see the world differently and I could perceive it by making many hundreds of drawings." His subject matter frequently was mundane while at other times his art hauntingly depicted life in the ghetto. He was especially intrigued by the thought of drawing "the Munk." Here Fleischmann considers how he might develop the boss's portrait in geometrical terms according to Cezanne's cubist style:

I have repeatedly tried to draw him. It's not easy. ..I made a whole lot of drawings with little success. Dr. Munk says about himself that he does not have a photogenic face. Maybe he is right. [But] from a painter's point of view his face is not only most interesting, but his entire stature and movements which are like counterpoint in a subconscious composed symphony movement

I'll have to set up two, slightly upstanding but beautifully formed ears, above the ears a wreath of shining dark brown hair on the crown of the head something that once had been a bushy mane - without being impertinent…[now] a head which can be called bald.. It should not be [overemphasized] because this is a weak point of the otherwise brave Maccabee…The head, although small is proportional to the upper part of the body [and] establishes symmetry and almost a monumental impression. Yet the most remarkable are the eyes - dark, deep, seemingly with no transition from the pupils to the iris, shadowed by the sleeplessness of long nights, supported by some striking crossbeams under the sunken cheeks.

The center is marked by an aristocratic finely-cut nose betraying a strong spirit, a proud person; it is a brave man who is facing you. In the physically small head lies a mighty brain. This small head is not the way a puppet's head is put on. It is a real organic entity, an integral part of the rest of the body. It's also the hands that impress you so. They are big, much too big for the small face but not malformed or clumsy, quite the contrary. They are strong and betray knowledge and feeling for what they hold… These are the hands of an energetic, yet gently touching surgeon.

When you see the gaunt man with his inflamed eyelids and tired mouth, how relentlessly he works for the welfare of the Ghetto inmates… then you can't lag behind him. For me personally, Dr. Munk has become a real experience. Rarely have I met people of his stature. It will be an honor for us all to be able to say that commissioned by the Health Department of Ghetto Terezin we were permitted to work together with Dr. Munk.

(Karrel Fleischmann's drawing of Dr. Munk is in the collection of the Art Museum at Yad Vashem.)

Remembering Karel Fleischmann

Karel Fleischmann began one of his last poems with these words:

Nobody will hear my song
The world of my time ends behind these walls.

But the doctor was mistaken. After the war's end, more than a thousand of Fleischmann's drawings, written notes and poems were found and collected in archives in Czechoslovakia and Israel. They provided valuable testimony because as doctor-artist-writer he was able to see and record the entire panorama of suffering including hunger, fear, overcrowding, sickness and brutality. Gradually the world became aware of Karel Fleischmann's unique contribution but only a small amount of written material was translated into English. Then in 2004 an article appeared in the International Journal of Dermatology which described the doctor's life. The authors Leonard Hoenig of Florida and Tomas Spenser and Anita Tarsi of Israel concluded their review by noting that although Karel Fleischmann perished, his dream for a better future endured, declaring that it is up to each of us to help make it a reality.

This blog essay has been adapted from a longer paper.

References and Acknowledgements

Primary material that has been reproduced here in italics was extracted from unpublished documents found in files of the Theresienstadt Martyrs Remembrance Association, Beit Theresienstadt (BT) at Kibbutz Givat Haim-Ihud in Israel. These had been translated by others into English and, in turn, I have slightly edited or resequenced portions for the sake of coherence. If in the process, factual errors may have inadvertently occurred, they are my own responsibility. Lydia Shmolka of BT translated some documents into English from their Health, Altestenrat and Erich Munk files. Several of Dr. Fleischmann's journals and poems which depicted the doctor-writer-artist's prewar work were translated into English by Hana Houskova and reproduced an unpublished biography Rack of Time (BT Karel Fleischmann File No. 601.) Other useful sources were Vera Schiff's memoir Theresienstadt: The Town the Nazis Gave to the Jews (Toronto: Lugus, 1996) and Ruth Bondy's Jakob Edelstein. Elder of the Jews (New York: Grove Press, 1981.) The best English language biography of Dr. Fleischmann is the reminiscence Dr. Karel Fleischmann: The story of an artist and physician in Ghetto Terezin by Leonard J. Hoenig, MD, Tomas Spenser, FRCGP and Anita Tarsi of Beit Theresienstadt (International Journal of Dermatology 2004: 43. 129-135) and the accompanying Commentary by A. Bernard Ackerman, MD The Importance of Remembering Karel Fleischmann. I wish to acknowledge Oded Breda, the manager of Beit Theresienstadt, and historian Dr. Margalit Shlain for their constructive suggestions.

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

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

The Beginning

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

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

A Door Opens

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

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

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

Field Work in Narrative Medicine

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

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

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

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

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

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

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

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

Fieldwork: Oral History, a Narrative Application

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

Full Circle

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

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

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

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

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

Medical uncertainty is all around us

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

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

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

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

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

Uncertainty and temperament

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

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

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

Comfort with uncertainty drives specialty choice

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

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

Uncertainty invites [other] answers

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

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

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

Your tests show

the numbers 73, 90, 119 and 2.5,

the letter A,

the color yellow,

a straight line interrupted by a repeating pattern

of steeples and languid waves

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

Normal’s a shell game you seldom win.

Take my advice. Enjoy good health

not as your due but the blessing it is

like Spring, laughter,

death.

Conclusion

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

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

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

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

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

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

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

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

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

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

Felice Aull

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Commentary by Mary Spano, Medical Photographer, The Institute of Reconstructive Plastic Surgery, NYU Langone Medical Center. Spano's work is on exhibit from June 29-August 31 in the Smilow Gallery at NYU School of Medicine. Free and open to the public.

In October of 2006 I joined the team at the Institute of Reconstructive Plastic Surgery at NYU Langone Medical Center, as its medical photographer. At the time, I was a professional photographer with a 20-year commercial background. In addition, I had worked as a Radiologic Technologist over the years to keep my photography career going, but I wasn't sure what medical photography was. I soon found out that I had gotten my "dream job." It combined everything that I loved about photography and knew about medical imaging. My job is to photograph people with facial differences, mostly children, and to provide diagnostic images for our doctors to plan surgeries that change those children's lives.

In the beginning I photographed pre and post surgical protocols. Many of our patients are young and vulnerable; they are apprehensive about everything "clinical." I began building my studio as a child friendly environment. I brought in child-sized posing chairs, dancing toys, and bubble machines - anything that would make the children comfortable enough to obtain the diagnostic photographs that the surgeons needed to plan their surgery.

Then one day around Christmas 2008, I was photographing a small child who was particularly apprehensive about letting go of Daddy's hand and I asked him if he wanted Daddy and Mommy in the photo with him. He said yes, and the "Family Portrait Project" was born. I took that first portrait not knowing what it would mean to the families or our department. Here, our families can sit for a portrait in a private setting, without any inhibition. Many of our families might not otherwise have a family portrait. These portraits are now displayed at the Institute in the gallery in our conference room.

The portraits have become the face of the Institute. They also help the staff illustrate to new families that whatever they may face along their path, they have the support of everyone at the Institute as well as the families we treated before them.
Working at the Institute is the most humbling and rewarding experience that I have ever had. I enjoy every day, and look forward to continuing to illustrate the incredible work the Institute does to transform the lives of children with facial differences.