"Give Me A Shot Of Anything: House Calls to the Homeless"

March 9, 2012 at 4:58 pm

Students at the NYU School of Medicine rotate through Bellevue Hospital during their medicine clerkship. Many of the patients they meet come from shelters or the street. Concern about how their patients live outside of the hospital is a topic that is often raised in the weekly humanism seminar I facilitate, so I was particularly interested in screening the recent documentary, Give Me a Shot of Anything: House Calls to the Homeless, to see whether it would be of interest to my students.

The documentary follows a dedicated physician, Dr. Jim O'Connell, as he cares for people living on the streets of Boston. The project began as a short film about the Boston Healthcare for the Homeless Program that runs the house call program, a hospital clinic, and the McGinnis House, a respite center for individuals who need transition care during an illness and have no home to stay during their recuperation. During production of that film, the director, NY based Jeff Schwartz, was so drawn into the lives of the people he met following Dr. O'Connell, that he decided to expand the project into an hour long documentary.

I interviewed Jeff in his New York studio a few days after he screened the film at Harvard School of Medicine. Following are excerpts of our conversation.

As he spent more time out on the street, the people he met began to open up to him on camera.

As we continued our conversation, I became increasingly uncomfortable with the use of the word "homeless" to describe the people who appear in the film. It seemed to me that it would be just as simple to describe people by name or where they were from, or how they had been trained. The word "homeless" had become a defining rather than a descriptive word, not just in this documentary but in the culture.

During the production Jeff became more attuned to the lives of his characters, and the experience changed his life.

To view the trailer please visit:
http://www.givemeashotofanything.com/

-Lucy Bruell, Editor-in-Chief

Painting the Brain

January 26, 2012 at 5:44 pm

Painting the Brain

Rachel Hammer is a third-year medical student and MFA candidate at the Mayo Clinic, and a guest blogger on the Literature, Arts, and Medicine blog.

Medical students are in the process of a professional transformation, and it can be cathartic to express those transformations artistically. One's conceptions of medicine, self, and one's professional identity may cycle through a myriad of forms The Mayo Clinic College of Medicine student interest groups in the humanities and in neurology partnered with the local art museum to host an evening entitled "Paint the Brain" in February 2011. This event consisted of an open invitation to medical students to paint their creative interpretations of the nervous system and the way it creates our human experience. The painting session was preceded by a brief presentation on art theory given by the art center's resident educator, Jason Pearson. Medical student, Lauren Jansons, then spoke on artists whose work has been affected by neurological conditions. Nearly forty paintings were generated.

The majority of the pieces were acrylic on canvas, some were mixed media using fabric, photography, duct tape, or water color. Examples of the artwork include: Andy Warhol-like portrayals of the midbrain, traditional Hmong art as neural gyri, trees of neurons, butterflies emerging from a woman's gut, abstract brains, the landscape of bare calvarium, and one's self portrait in the context of an aura. The paintings were shown on campus for National Brain Awareness Week and at the American Society of Bioethics and Humanities in October 2011. We repeated the painting session in January 2012 with a new topic: global health. Similarly, students were instructed to portray their own representation on the topic. Examples of the artwork from this session included: cervical dysplasia cells as an African mountain range, the earth upheld by many different hands, a closed water bottle hovering in a desert landscape, a woman's portrait overlaid with an anatomical heart, a hospital among gravestones, and a woman looking from a mountain top onto a sea of fog.

Feedback from both sessions was positive. From the first, the neurology student leader reflected, "My painting was inspired by the awe and wonder that filled me as I examined the anatomy of the skull for the first time. The bony cavity that cradles our brains is literally the seat of our conscious human experience and I find the architecture itself very dynamic. The vibrant colors and clear brush-strokes in this painting pay tribute to the constant pulse and flow of vitality through our minds, allowing us to appreciate each new thing."

Another student, a first year, Christine Tran, had this to say: "The painting session allowed me to carve time out of my busy schedule to mindfully focus on something other than the pathophysiology of disease processes or how one cell communicated with another. I didn’t realize it when I signed up to paint but this was a much-needed escape to refresh my mind. I needed to remind myself that… it was possible - and even necessary — to slow down and spend two hours finding just the right shade of beige to paint the contours of a woman’s face, and then to spend another hour giving her hair, highlights, and delicate tendrils. In fact, I enjoyed the exercise so much that when I didn’t complete my painting during the first three allotted hours, I walked back to the museum later in the week in snowy, ten degree weather to spend more time with my painting."

Physicians were invited to both sessions, but very few attended. From the second session, Dr. James Newman commented, "A blank canvas, an unlimited supply of acrylic paint, brushes, and a convivial crew of fellow artists-to-be. The topic was World Health… For me, having painted for many years, but not having touched a brush for too long to contemplate, this was a reawakening. I can't wait for next time."

Shakespeare once penned, "My nature is subdued to what it works in, like the dyer’s hand." So our minds are colored by the mediums we work in. It is refreshing, for a change, to allow color to do what thoughts do.

A Captain of His Ship

January 13, 2012 at 1:15 pm

This week’s guest post is written by Wil Berry, MD, a resident in psychiatry at NYU Langone Medical Center.

My patient, sporting a surprisingly fresh-looking plaid shirt, is sitting at a table in a courtroom on the 19th floor of Bellevue hospital. His hair, in the midst of a transition from sandy brown to silver, falls over his ears but is combed cleanly back to reveal friendly blue eyes. His beard, no longer grimy and tangled, is the color of concrete and full enough to obscure most of his tanned neck. He has been waiting for this moment for most of two weeks, as he has been telling me daily during our fruitless visits, and his posture is stiff with anticipation. I watch him shift his weight form one laces-free sneaker to another, his weathered face showing a softly confident smile, and realize that he looks both profoundly crazy and absolutely not dangerous. And I think, We are definitely going to lose.

The judge comes in, looking at no one, and Mental Health Court is in session. The tone of the regular participants — judge, attorneys, clerk — is flat and uninterested, a contrast to my patient’s jittery energy that makes him seem like a five-year-old at his father’s boring office party. When the clerk tries to swear my patient to tell the truth, he interrupts her to tell her that he can’t swear on a Catholic Bible because he knows the church’s secrets and they are after him. She assures him that he need not swear on any Bible, and he agrees to tell the truth adding "…so help me Christian God, Jewish God, and all gods of the earth."

The attending psychiatrist, my supervisor on the case, speaks first. He says that my patient is psychotic and unable to care for himself, that he has no place to live and has refused to take medication. He says that he is worried that if my patient is released from the hospital in his current state, something bad will happen to him. When he is asked if my patient has been hospitalized before, he replies that our hospital records show thirty-six hospitalizations. In response my patient stands, puts both hands on the table, and says, "Doctor, sir, that is a lie, I have been hospitalized over seventy times!" The judge asks my patient politely to sit down and wait for his turn to speak, and I can see his court-appointed attorney tugging the sleeve at his elbow. He sits, re-composed, saying gently "I’m sorry your honor."

My patient speaks with the unwavering sincerity of a fanatic, his cult composed of his own delusions, his faith reinforced by the doubting psychiatrists who try to diagnose and medicate him. When I first met him, the morning after he had been brought to the emergency room for trying to direct traffic in the center of a busy intersection, I offered him my hand. "Thanks Doc but you don’t want to shake my hand," he said, his voice relaxed and clear. "I just masturbated about twenty minutes ago. My body’s rejecting that chicken they gave us last night." As he stands now, answering questions in that same voice, eye contact warmly fixed on the judge, his demeanor and plaid shirt give him an air of both professionalism and small-town charm.

"Do you intend to hurt yourself?"

"No sir, your honor, absolutely not."

"Do you intend to hurt anyone else?"

"No sir, your honor, absolutely not."

Both parties have fallen into a rhythm, speaking their parts from memory. I wonder if perhaps my patient has spent more time in court than the boyish, court-appointed attorney at his side.

"And what will you do if you are released from this hospital?" Only now does the judge look at him, sliding his glasses down his nose and peering down from the bench.

My patient extends a finger towards the back of the courtroom, the nail long but clean; he is pointing east, to FDR Drive and the water beyond, to the grand and unfulfilled freedom of his future, and the pitch of his voice rises at the thought of it. "I am going to get a boat, your honor. I will be the captain. And I am going to clean up that dirty river."

Afterwards, in a hallway behind the elevator bank, my supervisor asks me why I think we lost. I tell him that I think our patient may have invoked a powerful American archetype, that of the harmless madman, a free-traveling, gray-bearded, hobo-esque schizophrenic who lives by his own code and prizes liberation above all else. I speculate that this symbol is essential to the narrative of our country, of our cities, and of the persistent presence of the seriously mentally ill living among us on our streets. I offer that perhaps it is a symbol which resonated with the court. He tells me that we just got stuck with a bad judge.

While my patient is packing up his room I go and see him to tell him goodbye and wish him well. I offer to see him next week for a follow-up appointment, which I assure him will not take place on the locked ward. He puts the appointment card in the pocket of his wool pants and tells me that he would like to come but doubts he will be available. He smiles at me and tells me that he has enjoyed our conversations. Later that day I sit at my desk, typing up notes and putting in lab orders for the next morning. The window to my right is bolted shut and reinforced with a wire safety guard but if I sit up straight I can see the city stretching southward, lights becoming visible as the sun begins to set. The river is to the east, bridges brimming with evening traffic, the water dark as a shadow between the boroughs, and I watch as a few boats make their way slowly southwards, moving out to sea.


MyRightSelf

December 21, 2011 at 1:48 pm

Arthur Robinson Williams is a PGY2 Resident in the Department of Psychiatry at New York University. He earned his M.D. and a Master in Bioethics at the University of Pennsylvania School of Medicine and Center for Bioethics. Williams studied photography at Princeton University with Emmet Gowin, Mary Berridge, and Lois Conner. His work, sponsored by an Open Society Foundations Documentary Photography Project grant, can be found at www.MyRightSelf.org.

The University of Toronto Press has recently published an anthology celebrating the 5-year history of its medical humanities journal Ars Medica. I have included excerpts from the article I first published as a medical student in the Fall 2008 issue of Ars Medica that has been reprinted in the anthology. The article grew out of a documentary photography project, MyRightSelf, that I developed with transgender individuals and couples in the Philadelphia area over the course of 2008 which was subsequently funded by an Open Society Institute Documentary Photography Project grant. Now working as a second-year psychiatry resident, the publication of the anthology has given me an opportunity to reflect on my travels- academic, clinical, spiritual, photographic, and otherwise- in the intervening three years.

Dane and Erin. "There are always things I think people would change about their bodies. I know no man whose chest is big enough, hairline is stable enough, abs are eight-pack enough. I don't think I am above all these influences. I wish I were taller and I wish my chest were without scars. Although they are fading slowly, my scars are pretty prominent."

Most striking is the loss I feel in acknowledging that this project was the last significant work of photographic portraiture I have completed. While I have occasionally engaged in some landscape work while vacationing, my long hours in the hospital during residency have largely eclipsed other meaningful forms of engagement and creativity in my day-to-day life. I have also found that successfully living in New York City demands its own toll- the scale, expense, and cacophony of the City adding to the fatigue engendered by 14-hour shifts.

Perhaps those are excuses however, rather than true explanations for the distance that has grown between my photographic lens and potential subjects. I remember writing in my personal statement when applying to residency programs:

The psychiatrist and the photographer have much in common. Whether relating to another person as a patient or a subject, both contemplate notions of identity and perception, of the Self. Both, at their best, similarly investigate their own biases in understanding those of others. Perhaps this is why Psychiatry felt so familiar to me- it was a role that I had already cherished. Part of what I was seeking in medicine was the opportunity to sit with someone, to be available to them, to learn more about the human experience.


Jake: "I gained confidence in my ability to pass, not only physically, but socially as well. From there I started going to gay bars-not to hook up, but just to be there, to be around gay men, again, to be in gay space that I felt safe navigating. I liked letting gay men flirt with me. It made me feel validated in my gender.

Clinical work in the mental health field is emotionally draining. I wonder if the reserve I needed to make photographic images has been otherwise spent on treating patients. The average doctor's day is filled with images, some radiologic, some metaphorical, others directly observed. Psychiatrists especially cultivate these images, drawing anecdotes, memories, and projections from their patients. The investment in this process consumes creative spirit as well as pathos. From Ars Medica:


For the participants with whom I have worked, the act of making a photograph has become-should be-as cathartic as the knowledge that the images will eventually reach a broader audience and as profound as the impact of the images upon viewers. For patients, likewise, the journey toward diagnosis and treatment may have as marked an impact on their latter years as their medical condition and/or disease state.

As a provider I have struggled not only to successfully complete a work up and treatment plan, but to find ways to enrich the process itself. Medicine-as-process, as a creative form imbued with empathy, becomes its own artistic medium in the act of naming and thwarting disease. Maintaining energy to do this well requires a source of renewal. I look forward to the day when once again this source may be found behind the lens.

A. Robin Williams, MD MBE
December 8th, 2011

Body and Soul: Selections from Ars Medica: A Journal of Medicine, the Arts and Humanities, was recently published by The University of Toronto Press. It is available at Caversham Books: (http://www.cavershambooksellers.com/search/1442612908).

Humanity Out of Context: Tinkers as a Touchstone for Dissection

November 3, 2011 at 3:19 pm

Editor's Note: I met Rachel Hammer, a third year medical student and MFA candidate at the Mayo Clinic, last month at the American Society of Bioethics and Humanism conference in Minneapolis where she presented a poster about a student poetry group. When I mentioned that I worked at Bellevue, she told me about a recent meeting at the medical school where the novel, Tinkers, was discussed in a narrative medicine group. Tinkers, as many of you know, was published by the Bellevue Literary Press and received a Pulitzer Prize for fiction. I asked Rachel if she would write about the group and its discussion of Tinkers.


Commentary by Rachel Hammer, MS3 and MFA Candidate, Mayo Medical School

The Mayo Clinic College of Medicine's Narrative Medicine group started in response to an ornament in Evelyn Waugh's Brideshead Revisited. A skull sits in a bowl of roses in the dorm room of Waugh's protagonist, Charles Ryder, in a section entitled, "Et En Arcadia Ego." Arcadia, legend has it, is the field described by Pliny the Elder where a shepherd wet his finger with spit and traced his friend's shadow against a tomb-the first painting-suggesting whilst setting the precedent that art is inspired when humans face their mortality. Art, thus, is humankind's response to death.

After hours in the medical school anatomy lab in the first year, we had stared at skulls and the dead long enough to stir substantial need for creative expression. A group of us began to meet to read poetry and excerpts from novels. I had read Rita Charon's Narrative Medicine, and visited the Masters Program at Columbia, where I learned some basic exercises in "attention, representation, and affiliation" and so I offered to facilitate the sessions. We are graciously funded by the Walt Wilson Art in Medicine grant. Our group meets for lunch once a month and is open to all medical students. Students sign up to attend, and we cap the group at twenty members. I choose the excerpts, usually something I come across in my MFA coursework.

For the October meeting I chose to read from Tinkers by Paul Harding, a work that I thought would resonate with first year students going through the emotional and physically arduous anatomy block. The excerpt (pages 178-184), was the touchstone for a discussion on experiences of cognitive dissonance when bearing witness to humanity out of context, such as the discomfort one may experience in dissecting a cadaver.

Tinkers is broken into segments with alternating narrators, Howard, the father, and George, his son, each tell the stories of their lives, with modest overlap. Real time in the book works backward, counting down the last days of George's life; time within memories works forward. Father and son as co-protagonists are like two gears, intimately related and yet spinning with force and purpose all their own.

In the excerpt, George, near death, loses consciousness in the living room where he lay in his bed surrounded by family. As always in our Narrative Medicine group practice, we read the passage to ourselves, closely, deliberately. Then we read the passage again, together, aloud. We then discuss what we recognize, what surprises us, and what it means to us, today, as we chance to encounter it.

We were struck by the language of natural elements Harding used to describe the dying bodies: Salt, wood, minerals, legs like planks, feet like lead weights, salt-cured, metal strengthened, dried veins, strong as iron chains, exhausted engine, bushings. Someone remarked that in other settings, when humans are described reductively in terms of their elemental components, their inner workings likened to the machinery of a clock, we are repulsed. How dare we consider humans as mere material! But in the space of death, written with the reverence of a poet, George returning to mere material is a beautiful, honorable fate. Recognizing that George spent his life as a clockmaker-that there was nothing for which he had more passion than clocks-his, then, is a righteous transfiguration indeed; that in death, he would morph to resemble the very thing he most loved in life, the wood, the chains, the lead weights, the bushings of a clock.

One student linked the end of the passage (p.184) to themes of TS Eliot (The Four Quartets was a previous reading in this group). She recognized the confusion of time in the space of death and grief-"imagining was as it is still approaching"-as a collision of past and future. Sharing our fears of death for ourselves, worry of bodily pain, we saw in ourselves the family Harding describes hovering around George:

(…"that they mourn because of the inevitability of the was and apply their own wases to the it [dead body], which is so nearly was that it will not or simply cannot any longer accept their human grief) as its broken springs wound down or its lead weights lowered for the last, irreparable time."

We discussed the extent to which our efforts in palliation and comfort are more for the provider than the patient. How some things are irreparable, and how seldom we can admit this to ourselves.

Since this passage was intended for the reflection of the first year students, as they loom over their assigned dead bodies like belated Fates, I asked them to reflect on the language in this passage while contemplating what it means to be dead, and what it means to encounter the dead. As you pick away at the crust of another human, now lifeless, out of context, consider the story that lies beneath. Our bodies, universes unto themselves, are, in fact, neither simple nor always logical, but ever so elegant.

Saying Goodbye

December 9, 2010 at 4:00 pm

EDITOR’S NOTE: Since this post first appeared we have resumed updating the blog.

After more than three years of blog postings, we are no longer adding posts. Our original aim was to bring many medical humanities voices, perspectives, and projects to the attention of those who are working in the field. To that end we published 78 invited entries by almost as many different authors. Our posts always began with an image, in keeping with our belief that art is an important element and resource for medical humanities.

There were discussions of what constitutes "medical humanities" and "biocultures." Writers told of new medical humanities initiatives they had instituted at their health care institutions and universities. We learned of experiments in narrative self reflection and creative writing. Often, there were constructive comments and interesting questions in response to our blogs. We invite you to browse, learn from, and enjoy these posts. We direct your attention also to several worthy medical humanities blogs that are current:

In the United States
Daniel Goldberg’s Medical Humanities Blog
Rebecca Garden’s blog on Teaching Disability in Health and Ethics

In the United Kingdom
British Medical Journal’s Medical Humanities Blog, edited by Deborah Kirklin
Medical Humanities written by a large group of contributors.

Thanks to all for your interest and participation.
Felice Aull, Ph.D., M.A.

Medical Humanities and Live Theater. See It Now!

October 6, 2010 at 2:33 pm

For those living in or near New York City, there are unusual opportunities to attend plays that bear directly on individual experiences of illness, altered bodily states, and the cultural and social context in which those alterations occur.

Still playing is Tony Kushner’s Angels in America at the Signature Theater Company."This play explores "the state of the nation"-the sexual, racial, religious, political and social issues confronting the country during the Reagan years, as the AIDS epidemic spreads. .. Characters in the play struggle to find meaning in a world apparently abandoned by God."
See annotation

Through December 19 is Harold Pinter’s A Kind of Alaska, together with The Collection at the Classic Stage Company. The play is partly based on Oliver Sacks’s book, Awakenings.

Recently closed: Wings, by Arthur Kopit: See annotation; Three Women, by Sylvia Plath: See annotation; Photograph 51, by Anna Ziegler (The race to understand the structure of DNA, with scientist Rosalind Franklin as a central character).

Posted by Felice Aull, Ph.D., M.A.

Four Years of Medical Humanities in Nepal: What Worked and What Did Not

September 12, 2010 at 2:56 pm

Everest region: Living in harmony with nature. Photograph

Commentary by P. Ravi Shankar, M.D. and Rano Mal Piryani, M.D., Department of Medical Education, KIST Medical College, Lalitpur, Nepal

In previous articles in the Literature, Arts, and Medicine blog we discussed sowing the seeds of Medical Humanities in the Himalayan country of Nepal; teaching Medical Humanities (MH) in English which, though the language of instruction, is not the native language of the participants; and also the challenge of creating and maintaining participant interest in MH.

MH was started as a voluntary module at Manipal College of Medical Sciences (MCOMS), Pokhara (1) and then we (PRS and RMP) conducted modules for faculty members at KIST Medical College (KISTMC), Lalitpur. In 2009 and 2010 we conducted modules for first year students at KISTMC. In this blog article we describe what in our opinion worked in the four modules and what did not and reflect on possible reasons for the same. Our experiences may be of interest to other MH educators, especially in developing countries.

What Worked

Small groups:

Small groups worked well in all four modules we organized and are an excellent way to learn MH. Small groups work together at a given activity and share ideas. In MH, unlike other more formal medical subjects, there may be no particular well defined solution of a problem. Participants mainly reflect on a painting, a case scenario, or a problem and share their views. In social sciences as opposed to the biological and physical sciences there may not always be a 'particular' way to solve a problem. One problem we faced was that not all members of small groups were active. We could only gently nudge the reluctant individuals into more active participation. We tried giving participants greater responsibility for self-managing small groups. We asked the groups to select from among themselves a group leader, a time keeper, a recorder and a presenter and rotate these roles during different sessions.

Paintings:

Paintings were a great success. We incorporated them more and more in successive modules. We have described our experience of using paintings in MH in a recent article. (2) Our major source of paintings was the Literature, Arts, and Medicine Database maintained by New York University. The database arranges literature excerpts, paintings, and videos according to different subject categories. Online access to photos of paintings and their annotations were useful. Participants were able to relate to the paintings, which were mainly from a western context. In Nepal only students from a science background take up medicine and most were not previously exposed to art appreciation and critical analysis of paintings. Most participants enjoyed the paintings but also recommended more use of art from Nepal.

Case scenarios and role-plays:

These were extensively used throughout. The case scenario usually had an ethical or a social issue which had to be explored wit role-plays by participants. A variety of issues such as diseases with social stigma, abortion, euthanasia, mental illness, patient confidentiality-among others-were explored. Student participants enjoyed role-play and interpreting different scenarios. Students brought out many issues and sometimes interpreted the scenario in a novel manner. Role-plays in KISTMC also served to bridge to a certain extent the language barrier as they were conducted in Nepali, the national language. We also introduced an exercise of interpreting scenarios depicted in paintings using role-plays, which was extremely popular with students. Interestingly, participants of the faculty module had problems with certain role-plays dealing with sexual and reproductive issues.

Debates:

Debates were used to explore certain issues in MH, for example, euthanasia, whether students from non-science backgrounds should be allowed to take up medicine, the nature of the doctor-patient relationship. Participants enjoyed debates but due to time constraints, full fledged debates-which require more thought and deliberation-could not easily be organized. Debates were more effective in the recently concluded MH module (2010). Students showed greater interest in the module as evidenced by their greater participation in group activities and high attendance (above 80%) even before assessments. In light of our previous experience, we modified the format so that the group/s speaking for the proposition would first put forward their points and then the group/s speaking against would counter those points. In addition to arguments prepared during the ten minutes allotted to the activity, students also had to oppose arguments put forward by the opposing group/s on the spot. We concluded that debates can be a good way to explore controversial issues.

Flip charts and flip boards:

These have the advantages of flexibility and ease of use. Flip charts are an excellent way for noting down the results of small group work and for small groups to present their findings to the whole house. We have been using flip charts effectively during Pharmacology practical sessions. During MH sessions flip charts were used to note main points and by presenters to guide their presentations. Flip charts are an excellent way for noting down the results of small group work and for small groups to present their finding to the whole house. On reflecting after the sessions it was our opinion that participants used flip charts in the same manner during both MH and Pharmacology practical sessions. Flip charts could have been used in a more creative manner during MH sessions. Certain groups did so but we could have developed and given guidelines to the groups. Creativity also may require a certain amount of artistic talent and ability among group members.

Venue of the sessions:

All student sessions were conducted in the college auditorium. The auditorium offers an empty space about 30 m x 30 m which can be arranged and organized to meet specific requirements. Students could be arranged in small groups with a separate area for role-plays and a main projection area. The only problem was the auditorium was being used for a variety of activities and we had to rearrange it before each session. A free area that can be reconfigured and rearranged to meet specific requirements is ideal for small group sessions that require creativity and flexibility, unless you can get a dedicated area for sessions, which can be difficult in developing nations.

What Did Not Work

Literature excerpts:

Literature excerpts have been widely used in MH sessions in the west. In the module at MCOMS, Pokhara, and in the faculty module at KISTMC we used literature excerpts. The excerpts were in English and participants often felt they were difficult to understand and the language was difficult. In MCOMS the participants were multinational. In KISTMC the major problem was getting literature excerpts in Nepali relevant to MH and the particular topic being covered. For English excerpts the Literature, Arts, and Medicine Database made the task easier as excerpts were arranged according to subject matter. We did not use literature during the two student modules; however, considering the complexity of issues which can be provoked and addressed by good literature we are thinking about how to incorporate it in future modules.

Reflective writing assignments:

MH is basically a process of reflection about various events in medicine. Reflective writing can be a good method to get participants to reflect. We tried giving reflective writing assignments to participants, but only participants in the MCOMS module, which was voluntary, were regular in submitting their assignments. Assignments were not used in the faculty module. In the 2009 student module submission was irregular. In the 2010 module students submitted more regularly. In South Asia compared to the west students are younger and less mature when they enter medical school. There is a dichotomy between arts and science in the education system. Creative writing and keeping a personal diary are not very common. These could be reasons why students were not very comfortable with reflective writing. However the interest and participation of the 2010 batch gives us hope that this could be a modality to be considered in future.

Medical Humanities online:

We created a medical Humanities group on the web (a private Google group). Slides of various topics, other material and selected publications related to MH were uploaded. There is also a discussion forum where individuals can discuss and comment on various topics. Participation in the group is voluntary. We invited selected faculty and other experts and sent an invitation to all students who participated in the module. Problems of net access, lack of time, and a hectic academic schedule were cited as possible reasons for not joining and not being active in the group.

Creating interest among other faculties:

Over the four years of MH only few faculty members were interested in being module facilitators. During the 2009 student MH module six faculty members from various departments joined as co-facilitators. Many of them were not entirely comfortable with small group learning and with using art and role-plays in medical education. Many were clinicians and their tight clinical schedule could have been a hindering factor. During informal discussion with western MH educators a factor which emerged was only faculty with a personal interest in the arts or with a hobby related to the arts like photography, painting, sculpture and creative writing may be interested in MH. Lack of success in creating new facilitators may be a limiting factor for the module in future.

Creating linkages with persons outside the traditional world of medicine:

In the west MH programs use resources and facilities from many sources. Artists, writers, philosophers and others have made a significant contribution to MH. In the west most medical schools are in a University sharing a campus with other disciplines while in Nepal medical schools usually exist in isolation. We were successful to a certain extent in that we wrote about using art in the education of doctors for a Nepalese magazine and created a certain amount of interest among people outside traditional medicine. The challenge will now be to transform interest into action.

The situation in South Asia is in many ways different from the west. Also batches of students and individuals vary in their interests and aptitude. Tailoring a module to meet the aspirations of groups and individuals is a challenge. Flexibility and an open mind could be important in meeting the challenge!

References

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

2.Shankar, P. R. and Piryani R. M. Using paintings to explore the Medical Humanities in a Nepalese medical school. BMJ Medical Humanities 2009; 35:121-122.

A Summer of Books

July 6, 2010 at 2:51 pm


Commentary by Felice Aull, Ph.D, M.A., Editor, Literature, Arts, and Medicine Database
. Now that summer is upon us, I hope you have access to a cool, restful place where you can burrow into a book and get lost in it. Here are some books I read during the past year or so that I found particularly absorbing, listed in no particular order. Perhaps some will appeal to you as well.

Novel, Await Your Reply, by Dan Chaon. A suspenseful, dark story of identity in which three parallel narratives eventually find each other. (Now available in paperback)

Nonfiction, Zeitoun, by Dave Eggers. A harrowing story, told simply and directly but with growing menace, of what happened to one Muslim American family during Hurricane Katrina in New Orleans. The hurricane was the least of their traumas. (Now available in paperback)

Novel, A Gate at the Stairs, by Lorrie Moore "Ms. Moore has written her most powerful book yet, a book that gives us an indelible portrait of a young woman coming of age in the Midwest in the year after 9/11 and her initiation into the adult world of loss and grief." Michiko Kakutani, New York Times book review. (Now available in paperback)

Novel, A Person of Interest, by Susan Choi. "…say[s] something about what it means to live in a society that is simultaneously tolerant and suspicious, inclusive and all too ready to punish its citizens for the crime of being their authentic selves . . . making us feel deeply for characters who are profoundly flawed. . . . beautifully written. Choi's precise, cadenced prose alternates between plain-spokenness and lyrical dazzle." Francine Prose, New York Times book review. (Available in paperback)

Short Story Collection by Jhumpa Lahiri, Unaccustomed Earth. "Most of Lahiri’s insightful writings concern the betwixt and between challenges associated with immigration and with generational shifts. This collection of engaging and beautifully written stories examines both challenges." Lois LaCivita Nixon, Literature, Arts, and Medicine Database. (Available in paperback)

Novel, Then Came the Evening, by Brian Hart. The author’s first novel is a story of people living harsh lives in the harshly beautiful landscape of Idaho. "Quietly exceptional". . . short review in the New Yorker.

Poetry: Unincorporated Persons in the Late Honda Dynasty, by Tony Hoagland. Hoagland is witty and observant as he focuses relentlessly on contemporary American culture.

Poetry: My Life As a Doll, by Elizabeth Kirschner. The speaker spins out "a narrative of embattled childhood" and its long-range effects.

Interdisciplinary Arts Project in a Family Medicine Residency Training Program

May 24, 2010 at 9:32 am

Photograph of pregnant woman with gold painted hand of partner on her abdomen

Commentary by Maureen Rappaport MD, FCCFP, Assistant Professor of Medicine, St Mary’s Hospital Center, and McGill University, Montreal, Canada

I am trained as a family physician but one third of my practice is as a clinical supervisor and teacher of residents in a family medicine teaching unit. I am based at St. Mary’s Hospital, a small community hospital in the heart of urban Montreal. Our residents have to do a "research" project as part of their training. Like most of our clinicians, I am not a trained researcher but I have had extra training as an educator (McGill Scholar in Medical Education 2004). A research project was a requirement of that program and through the courses I took in the Department of Education I discovered academic researchers were exploring different theories of knowledge and research (Barone and Eisner, Clandinin and Connelly, Cole and Knowles, and Patton)): i.e. Qualitative Inquiry, Interdisciplinary Artistic Inquiry, and Reflexive Inquiry. I used these methods in my own research project and although I initially met with skepticism, in the end my project was well received.

Past resident projects at St. Mary’s Hospital were mostly literature reviews and chart audits and, though interesting, the topics tended to repeat themselves year after year. My experiences in the Scholar’s program gave me the idea to propose an "Interdisciplinary Art Project" stream to my colleagues. I was excited about this new development, other staff members became inspired to develop other projects, and best of all, the residents engaged wholeheartedly with this new project paradigm.

I developed the guidelines for the Interdisciplinary Art Project based on work done by Dr. Ruth Martin, at University of British Columbia Family Medicine, who was generous enough to send me her documents. (Draft guidelines for Interdisciplinary Art Resident Project,Version #7, September 2005).

Interdisciplinary Art Project Stream Guidelines

Goals:

To integrate an artistic activity that includes photography, painting, sculpture, music, poetry, drama, film, or creative writing in a project that contributes to the existing knowledge base of Family Medicine

  1. To increase clinician self-understanding and/or understanding about the physician patient relationship
  2. To produce an oral/visual/audio/performance presentation which consists of the work of art itself AND
  3. To produce an abstract and a report written in a format similar to scientific research, however, you may write this report in the first person like a personal diary or field notes

Objectives:

  1. Demonstrate an academic understanding of the integration of the chosen artistic discipline with the discipline of family medicine
  2. To produce a scholarly work that attempts to understand, explain, and/or interpret a clinical question or enigma and to explain your motivation for choosing an artistic medium
  3. To include a historical and contemporary overview citing past examples of interdisciplinary work
  4. To explain how your project relates existing interdisciplinary knowledge or published literature
  5. To outline the ethical considerations encountered. ( Physician artistic activity can lead to ethical conflicts between what is research, art, or journalism, or when artistic activity interfaces with clinical care)
  6. To fully explain your methods ie. why, when and what materials/medium were used and if other participants were involved what consent process was used and did they have input in editing
  7. To present your results (the work of art) and a summary of the written report on resident day
  8. To have a full discussion about the impact and limitations of your project
  9. To demonstrate how the process of completing an interdisciplinary art project resulted in your personal growth or increased understanding

Preliminary Project Excerpts for Research Day June 16, 2010

Four projects are in the Interdisciplinary Arts Project stream this year:

1. The Exploration of a Patient’s Experience with Injury, Illness and Healthcare in Montreal -A short documentary film (Dr. Isaac Berman)

2. Poetry Therapy (Dr. Anne-Marie Leblanc)

3. Narrative Medicine, A Reflection (Dr. Tara McCarty)

4. Life-casting Project of Pregnant Woman and Her Partner (Dr. Tim Lussier)

Below are excerpts of three projects in their preliminary form:

Poetry Therapy: Anne-Marie LeBlanc

"As [Arthur] Lerner [is reputed to have] said, ‘poetry has the potential to help you be your best possible self… it brings us back to our own humanity’. I think I could say this is exactly what poetry brings me: humanity."

Outline of Project

  1. Intro
  2. Development
    1. History of Poetry Therapy
    2. Poetry and humanity
      1. Presentation of poems
    3. Research Method
    4. Four beneficial effects
      1. "Finding the Words to Say It"
      2. "It Takes a Whole Doctor to Treat a Whole Patient"
      3. "Paying Witness to the Unfolding Occurence of Life Itself"
      4. "Becoming a Better Professional"
  3. Conclusion

"The poem named ‘Une Femme Morte’ was written during my palliative care rotation."

Une femme. Morte.

Et moi qui entre

Devant elle

Un regard, en fait deux

L’un eteint et l’autre en peine

Deux coeurs

Qui ont aime… et cesseAd’aimer.

Trop difficile cette vie

La-haut ce sera plus calme…

Et la musique quiAla transporte

Je souffle sur son ame

Et reviens sur Terre

Lui ouvre les yeux…

Rien.

Que du vide. Que du vitreux

De l’ordinaire extraordinaire

Incroyablement effrayant.

Saisissant.

Le rideau derriere moi

Je le saisis. Un dernier regard

Trite, livide.

Je la laisse

Et je marche hors de moi.

Narrative Medicine, A Reflection: Tara McCarty

"This is a little piece I wrote in the call room last week after a particularly difficult night. Small reflections such as these are known as narrative medicine. AThe doctors, nurses and staff who care for the ill are exploding with stories of beauty, sadness, and unique information that they are privileged to know about their patients’ lives. Narrative medicine, as described by Rita Charon, internist and writer, is a way of practicing medicine that enables the physician to practice it with empathy, reflection, professionalism and trustworthiness. It can be conceived as a model for a new way to practice medicine, a way that perhaps is a form of reincarnation from the old."

It’s late in the evening and I’ve been paged by the attending who asked me to see Mr McDonald. He hadn’t been doing well and the attending wanted me to check on him and re evaluate his pain control later on tonight. Actually, I knew this patient from a couple months ago when I was on call- a sweet 91 year old man who still had all his mental capacities and a great photo of his nine grandchildren by his bedside. He came with pancreatic cancer and a CVA, and when I saw him, he was desatting and short of breath from a likely aspiration pneumonia. On top of that, he had gone into fast a fib at around 160, and at 4 am, alone on the eighth floor, I put him on a monitor and pushed some IV metoprolol until he slowed down.

Once my heart rate and his were both down to the double digits, he smiled at me, amused. "It’s Ok, my dear", he said, "You don’t have to look so worried anymore". When I left later that morning he was satting well, had a heart rate of 70-90 and he patted my hand gently when I left.

Tonight, I go in to check on him. Much has changed. He has had two more CVAs, and he is now Level 5 care, existing on that lovely trifecta of nasal prong O2, morphine and scopo. I walk into his room, introduce myself, explaining that we have met before. He is breathing at about six during the minute that I count but seems to be focusing on my eyes. I realize the sound that is coming from his throat is what we doctors so eloquently call "the death rattle". I am holding his hand and with my free one press the call bell to ask the nurse to phone his family, but once she answers, the only one left breathing in the room is me. Mr McDonald, the sweet man who only a couple months ago had told me to "stop being worried", had just died, here in front of me, his hand in mine.

In a haze, I did the usual, the exam needed to pronounce, the papers, the signatures, the call to the family, helped the nurses clean him up, take out the IVs, take out the foley, take off the EKG stickers. I left his peaceful body in his room, waiting for his family. But his spirit stayed with me for a while. I left his room and walked down the dark hall, Mr McDonald’s ghost floating beside me, calm. And so he walked beside me, holding my hand, all the way from 5 main to 5 south, and then he let me off at the elevators. I pushed the down button for me, and the up button for him. His elevator came first, and he waved softly and smiled as the doors closed, his eyes once again telling me that everything was OK.

Life Casting of a Pregnant Woman’s and Her Partner’s Hands

Resting on Her Belly: Timothy Lussier

Introduction: The bond between a family and the unborn fetus is not very well discussed in the medical profession as the pregnancy is quickly reduced to a checklist of symptoms and signs. Art can help to capture this relationship in a way that is informative and powerful for the observer whether it be a patient, passerby or the responsible physician. Objective: Use sculpture to help capture the bond between the mother, partner, and the unborn fetus. Design/Method: Research aspect-to explore what is known concerning the bond between the mother/family and the developing fetus; Creative arts aspect-life-casting project of a pregnant woman and her partner symbolically representing the connected union. This will be followed by a survey of observers to verify the art assists in the intended purpose. Results: 1) Written report 2) Sculpture 3) SurveyADiscussion: Art can be a transforming experience and has shaped minds and history through time. It is our way of expressing complex ideas or emotions and communicating this to others. The nine months of pregnancy is a powerful experience for the family not formally recognized by the mother’s interaction with the medical profession. A life-cast sculpture of this bond may help us to better understand this experience and promote this experience within the family.

The above excerpts are just tastes of what these projects hold. I can’t wait for research day, to hear my residents present these works to their peers and my colleagues, to see poetry, stories, and art next to evidence- based searches. Medical Humanities has taken yet another place in the Academy.

Note: Although the projects are in various stages of development the residents have generously agreed to share their work so far.

References

Barone, T.E. & Eisner, E. (1997). Arts-based educational research. In R.M. Jaegar (Ed), Complementary methods for research in education. (2nd Ed.) (pp.73-116). Washington, D.C.: AERA.

Clandinin, D.J. & Connelly, F.M. (2000). Narrative inquiry: Experience and story in qualitative research. San Francisco: Jossey-Bass.

Coles, A. & Knowles, G.J. (2000). Researching teaching: Exploring teacher development through reflexive inquiry. Boston: Allyn and Bacon.

Lerner, Arthur. Cited by McARDLE, S. and BYRT, R., in Journal of Psychiatric & Mental Health Nursing. 8(6):517-524, December 2001. p. 521.

Patton, M.Q. (2002) Qualitative research and evaluation methods. Sage Publications: California