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.