Richard Selzer and Ten Terrific Tales

July 20, 2016 at 9:23 am


Richard Selzer and Ten Terrific Tales
selzer
by Tony Miksanek, MD
Family Physician and Author, Raining Stethoscopes

If there were a Medical Humanities Hall of Fame, physician-writer Richard Selzer (1928-2016) would be a first-ballot selection. And likely by a unanimous vote. The diminutive doctor had a very large presence in the field. He energized the medical humanities movement in the 1970's and 1980's with his lectures, readings, writing workshops, commencement addresses, correspondence, personality, and kindness. But it was his writing - earthy and elegant, whimsical and wise - that masterfully mingled the world of medicine with the world of the arts and highlighted the necessity of humanity in health care.
His literary output includes more than 125 published short stories and essays, a work of nonfiction (Raising the Dead), an autobiography (Down from Troy), a novella (Knife Song Korea), and a diary (Diary). Many of his stories reflect an interest (even an infatuation) in decay and death, the beauty of the body, how illness beatifies the sick individual, the power and fallibility of doctors, and the great panacea/contagion - love.
"Writing came to me late, like a wisdom tooth," Selzer proclaimed. Indeed, he was 40 years old when he began writing seriously. His early efforts at crafting stories dutifully occurred between the hours of 1:00 and 3:00 AM. His initial focus was creating horror stories because it was an "easy" genre to handle. That fondness for the macabre and otherworldly never dissipated as he continued to utilize horror (and humor) in many tales. The majority of Selzer's stories involve doctor-patient relationships, surgery, and suffering. Some of his literary work is weird ("Pipistrel"), experimental ("A Worm from My Notebook"), and an exercise in reimagining ("The Black Swan Revisited").
Surprisingly for an MD, he seemed a bit unconcerned about facts in his writing. Rather, he was deeply interested in creating impressions. For Selzer, facts weren't necessarily equivalent to truth. After all, facts change but impressions endure. Still, Selzer stubbornly searched for truth (and love) in his stories. He was enticed by language and the sound of words. From time to time, he manufactured his own words. He disliked gerunds but appreciated onomatopoeia. His favorite doctor-writers were John Keats and Anton Chekhov both of whom died from tuberculosis - Keats at age 25 and Chekhov at age 44.
I don't know which story Richard Selzer considered his best or most beloved, but I suspect that "Diary of an Infidel: Notes from a Monastery" was at or near the top of his list. The rest of us, however, definitely have our favorite Selzer stories. And while there are so many wonderful tales to choose from, I recommend the following 10 not-to-be-missed selections. My list is divided into two sections. Part 1 includes personal favorites and stories that don't get nearly the attention they deserve. Part 2 is comprised of stories and an essay that I find very useful in teaching.
Part 1: Five Fabulous Favorites:
1. "Tom and Lily"
2. "Luis"
3. "The Consultation"
4. "Toenails"
5. "Fetishes"
Part 2: Five Fixtures for Teaching:
1. "Brute"
2. "Imelda"
3. "Sarcophagus"
4. "Wither Thou Goest"
5. "The Surgeon as Priest"
So there you have it. The two greatest stories by Richard Selzer are "Brute" and "Tom and Lily." Of course, that's just my opinion. How do you see it? You are invited to post to the blog with your favorites. (I have a hunch that "Imelda" is going to vie with "Brute" for the top spot.) In the meantime, The Doctor Stories by Richard Selzer is a perfect place for readers to roost - either as an introduction to his work or an opportunity to reacquaint with some notable tales.

Medical Humanities - Initiating the Journey at Xavier University School of Medicine

August 26, 2014 at 11:30 am

Dr P. Ravi Shankar has been facilitating medical humanities sessions for over eight years, first in Nepal and currently in Aruba in the Dutch Caribbean. He has a keen interest in and has written extensively on the subject. He has previously written several pieces for the Literature, Arts, and Medicine blog.

I have always enjoyed facilitating medical humanities sessions right from the time I facilitated my first voluntary module for interested students at the Manipal College of Medical Sciences, Pokhara, Nepal in 2007. The energy level during the inaugural module was incredible. The participants, both students and faculty, and I really enjoyed the evening sessions and the feeling of freedom and discovery as we did various activities and discussed different issues. We had a lot of fun.

When I joined Xavier University School of Medicine (XUSOM), on the beautiful island of Aruba in January 2013, the Dean, Dr Dubey was keen that I facilitate a medical humanities module for the undergraduate medical (MD) students. The school had just shifted to an integrated, organ system-based curriculum from the traditional discipline based model common in offshore Caribbean medical schools. Didactic lectures were the main teaching-learning methodology but the school was working towards introducing small group activities and problem based learning sessions. I decided to facilitate a short medical humanities (MH) module for the incoming first semester students.

At that time the school had only lecture rooms and a traditional desk and chair seating arrangement. Luckily the desks could be rearranged, and I conducted my first session in the lecture hall with the students arranged in four small groups. Some of the students had completed a premedical course of study in the institution and were only familiar with lecture based-teaching. Small group activity was something new for them. Medical humanities do not occupy an important position in the United States Medical Licensing Exam (USMLE) Step 1, and students in Caribbean medical schools focus on step 1 preparations. Subjects which are not tested or tested less in step 1 are not considered important. MH is thus not commonly offered in offshore schools.

The first group of students: I concentrated on six topics for the inaugural and subsequent medical humanities modules. These were empathy, the patient, the family, the doctor, the patient-doctor relationship, and the medical student. The modules were activity based and I used case scenarios, role-plays, debates and paintings to explore different subjects. The learning objectives of each session were listed in the study outline posted on the class server and also highlighted at the beginning of the sessions. For example, for the session 'The doctor' had these objectives:

At the end of this session students will be able to:
•Obtain a perspective on what it means to be a doctor
•Explore balancing a meaningful personal life with a busy and rewarding professional career
•Understand 'certain' influences and pressures on a doctor today
•Interpret the changing role of doctors through paintings and stories

Certain students enjoyed the freedom and flexibility offered by the module while others tended to 'misuse' the freedom. I had a few disciplinary issues which I had to deal with carefully as I did not want students to feel intimidated. I did not confront the students with disciplinary problems during the class but had a quiet word with some of them after the session. The formative assessment rubric addressed issues like attendance, punctuality, discipline and commitment and students who worked harder and showed greater commitment performed better in the assessment. Also for each session each small group had a group leader who was responsible for keeping the group active and focused on various tasks. The role was rotated during different sessions. I wanted them active, focused and interested in the activities and the subject. Among the various activities employed, students eventually did well in interpreting paintings and in the debates. The role-plays however needed more work. They often did not explore the issues in sufficient depth and students felt inhibited to act out certain scenarios in front of their classmates. This was in contrast to the students in Nepal who had enjoyed the role-plays with their skits and acting became richer and more complex as the module progressed.

Two of the role-plays I introduced were:
1. Ms. Mohini is a 28 year old lady from South Asia who was trafficked and was compelled to become a commercial sex worker. After ten years of service she was sent back to her country and village as she became HIV positive. The disease is at an advanced stage and she has no money for treatment. Her family has reluctantly allowed her to stay with them but is not happy that a retired prostitute is living with them. Explore what it means to be sick using a role-play. (Used during the session 'What it means to be sick')
2. Dr. Richard is an Internal medicine specialist in Toronto. He has been treating a twenty-two year old college student named Rachel for the last five years. The lady suffers from severe attacks of migraine and is on drug prophylaxis. Richard has realized that he is in love with Rachel. He wants to live happily ever after with her. However, he is not sure about whether it would be correct for a doctor to marry his young female patient. Analyze the issues involved using a role-play. (Used during the session 'The patient-doctor relationship')

Among the different cohorts of first semester students I found the fall 2013 and the spring 2014 cohorts to be the most interested and active (XUSOM, like most offshore Caribbean medical schools, admits students three times a year in January, May and September). These students created interesting role-plays to explore various issues based on the scenarios provided. The debates and the interpretation of paintings were also rich and varied. I enjoyed facilitating these groups. These two cohorts had a few students who were active, dynamic and committed and with good leadership skills. They were able to motivate and stimulate their colleagues to give their best. They also had good acting skills, which was useful during the role-plays. With greater exposure to small group learning these cohorts were more comfortable with group work and the academically stronger students were more willing to support students who were less strong academically. Class sizes at XUSOM are small and till date around 90 students have completed the program.

Co-facilitators:

At XUSOM many students, though American or Canadian citizens, are of South Asian or Middle Eastern descent. There were no major cultural and other problems involved for me in facilitating this group of students. Many students were interested in this new perspective and in understanding the art of medicine. XUSOM also offers courses in English and scientific communication to premedical students and the faculty members teaching this subject eventually joined me as co facilitators during the module. They were from a liberal arts background and were able to offer a 'different' (often a layperson) perspective during the various activities and the discussion. A challenge I faced similar to Nepal was that not many 'medical school faculty' were interested in MH and in co-facilitating the module, though two or three did attend certain sessions.

Small group learning room and other developments:

Over the preceding twenty-month period MH has become an accepted part of the school curriculum. The school created a separate room dedicated to small group learning with comfortable seating, white boards, flip charts and projection facilities. The room is now being used for various small group activities including problem based-learning. Slowly there is a greater number of small group learning and self-directed learning activities at the school. MH is now an established discipline at the school and the module is a part of the patient, doctor and society module for first semester students. Students' ability to show empathy, make their patient feel comfortable and obtain a proper history is assessed at the end of the first semester using standardized patients. Students also visit a local general practitioner every fortnight to learn history taking skills and interact with patients. I am sure MH will progress and grow in the sunny, hospitable climate of the one happy island of Aruba in the Southern Caribbean.

You can learn more about the MH modules in a forthcoming article in the Asian Journal of Medical Sciences titled 'Four semesters of medical humanities at the Xavier University School of Medicine, Aruba.' (in press)
Photos courtesy of Dr. P. Ravi Shankar

Two Doctors, Two Generations: Q&A with Dr. Barron Lerner

June 23, 2014 at 12:11 pm

On May 6, 2014, Barron Lerner, MD, PhD, kicked off the Lerner Lectureship series with a talk that explored the evolution of medical ethics through the lens of his father's and his own practice of medicine. Dr. Lerner's father, Phillip I. Lerner, MD, was "a revered clinician, teacher and researcher who always put his patients first, but also a physician willing to 'play God,' opposing the very revolution in patients' rights that his son was studying and teaching to his own medical students." The talk built upon Dr. Lerner's new book, The Good Doctor, which touches on issues of patients' rights, autonomy, generational friction, and the remarkable bond between father and son.

Below, Dr. Lerner discusses some of his father's unique stories and what it means to be a "good doctor."

The Lerner Lectureship is generously supported by Sam Miller, a grateful patient of Dr. Phillip Lerner.

Why did you write The Good Doctor?
There are several reasons. First, when someone is a historian of medicine and had a father who kept copious journals about his career as a physician, it is hard not to imagine fashioning this information into a book. Second, including medical school, I have now been in medicine for thirty years. To the degree that I have achieved some wisdom, I figured it was the time to reveal it. Third, my agent, Robert Shepard, has been trying to get me to write a trade book forever. So I finally succeeded. Fourth, and most important, the book is a tribute to my father, who I believe exemplified what it means to be a "good doctor." It is a taller task these days, but one I think that those of us in medicine should try to embrace.

What did you learn about your father from his journals and your other research?
The main "finding" about my dad's career was how he felt it was his duty, having mastered the scientific literature and learned as much as possible about his patients' lives and values, to make the right clinical decisions for them. This made him an unabashed paternalist and someone who, in certain circumstances, was even willing to mislead patients to get them to do the "right thing." As his career progressed, and bioethics and patients' rights emerged, he begrudgingly began to incorporate some of the new dogma about informed consent into his practice. But he remained strongly opposed to the reflexive use of algorithms and the practice of giving patients menus of diagnostic or therapeutic options. He believed that these approaches were not congruent with the true practice of medicine.

What were some of the most interesting stories you discovered?
Well, I guess you could say there were good and bad ones. One of my favorites was the time that my father got an elderly Orthodox Jewish woman to agree to an open lung biopsy by getting one of his infectious diseases buddies, who was a devout Catholic, to do a consultation on the patient. When this doctor took out his rosary to pray for the woman, she could not say no. In another case, my dad not only diagnosed meningococcemia, a severe bacterial blood disease, at a patient's home, but deduced that she had recently been playing tennis by the fact that the rash was worst in the area of her right forearm.
On the flip side, there is the story that starts the book in which my father placed his body over a recently-deceased patient to prevent his colleagues from resuscitating her. As the patient did not have a DNR order, this violated both the legal and ethical standards of the day. He also tried to get doctors and nurses to give both of my extremely-ill grandmothers enough morphine to get them to stop breathing. But even in these instances, my dad was acting according to his fervent beliefs about what it meant to be a compassionate doctor. After preventing the CPR, he wrote that he had acted based on his "30+ years as a physician responsible for caring and relieving the pain of my patients who can't be cured."

What lessons do your dad's and your medical careers reveal for future physicians and health care reform?
I would first point out that there is no going back to the paternalism of my dad's era. Patients' rights are here to stay. Plus, modern doctors do not have the time to practice the intensive, patient-centered care that my father did. But there are ways in our modern system to replicate some of what my dad did and stood for. There is a bit of a backlash against patient autonomy, for example. Patients may be quite willing to take advice from physicians that they know and trust, even about end-of-life issues. And although office visits may be only 15-20 minutes, it is still possible to spend a few minutes discussing what is going on in a patient's life. I like to write down what we discuss in my notes and bring it up at the next visit. And the doctor-patient relationship does not only have to occur via face-to-face encounters. Innovative programs are using phone calls, Skyping and e-mailing to allow busy physicians to stay in better touch with their patients.

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

March 13, 2008 at 10:46 am

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

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

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

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

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

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

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

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

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

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

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

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

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

What Is Medical Humanities and Why?

January 25, 2008 at 11:25 am

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

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

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

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

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

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

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

Medical Ethics on Stage

January 11, 2008 at 3:33 pm

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

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

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

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

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

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

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

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

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

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

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

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

Further Reflections on Medical Humanities

December 22, 2007 at 3:32 pm

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

 

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

Medical Humanities: Education or Entertainment?

November 8, 2007 at 4:46 pm

Medical Humanities: Education or Entertainment?

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

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

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

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

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

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

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

October 7, 2007 at 3:14 pm

Nicole Hefner and one of her students

Commentary by Nicole Hefner, Teaching Artist for Teachers & Writers Collaborative and Language Lecturer at New York University

For the past decade I've taught poetry to children with moderate to severe learning and mental disabilities in the New York Public Schools. Spring after spring, armed with little more than a bottle of water and a healthy stash of yellow #2's, I've entered the classroom. My work with these students has never stopped satisfying me on the truest and deepest levels. I visit; we write poems (almost always through dictation) and then the students trace, squiggle or have the help of hand-over-hand with a paraprofessional or teacher onto their own paper, making the poem more fully their own. At the end of the term, the poems are compiled and distributed in an anthology; cake is eaten and we wish our summer farewells, bidding all goodness until springaand poetry!acomes again.

This past May, however, my heart broke a little. I should say I've been at one particular school in Staten Island for all of my teaching artist years. My relationship with the staff is extremely rewarding, matched only by my relationship with the students. One particular young woman, I'll call her S., now 20 (students remain in New York's special education system until they're 21), has been in my class for five of the past six years, and so, I was especially happy to see her when I walked into her third floor classroom. Ms. Poetry, another student yelled, and although S. did look up at me she did so with little recognition. After a bit, she broke into a smile. Oh, she said with an overly dramatic hit to her forehead. Now I remember you.

But I could tell she didn't. Not at first, anyway, and then only in pieces. I was okay with that; maybe I looked different, I reasoned, and hmm, I thought to myself, I did seem to remember her having trouble with vision. But poetry! I said (surely too loudly). Of course, you remember poetry! There were other students in the room who I'd also taught for a number of years. I looked around at the silence. I said again. Langston Hughes? Dreams? For the love of cake, somebody's got to remember poetry. I smiled and looked at the teacher who shrugged sympathetically. S? I said (at this point I was flapping birdlike and pacing the linoleum). You know poetry. We do it every spring. You love it.

Again, the gesture: the palm to the forehead. Oh, now I remember, she said.

The light through the high windows held the dust in the air, and we moved on; we had to. There was only just enough time to get a poem written. At the end of our spring together, the poems were as beautiful and powerful as they have been in past years, and, yes, S. seemed to love poetry every bit as much as she always had, but I had changed.

When I first started teaching children with disabilities, I had a conversation in the school cafeteria with a teacher who was a thirty-year veteran. You have to change all of your expectations, she told me. Maybe, she said and pointed in the direction of a nonverbal 19 year-old, huge and burly and wild-eyed, who sat rocking and chewing on his hand as those with autism sometimes do to feel the stimulation. Maybe, today, he will hold a pencil in his hand. Maybe, he won't. You have to love them for what they can do; you have to get them to do what they can do.

I fear sometimes in the quest of being dynamic teaching artists we get so wrapped up in the art that we forget how real the students are. Our final products with their perfect-bound spines and their color covers may sit untouched on bookshelves for years as the very students who created them can't even read them. So intent are we on guiding the students to compose wildly imaginative poems and funky abstract paintings, we neglect their pain and frustration; we overlook their illness. Perhapsaand this may sound extremeawe go so far as to de-humanize them in the service of art.

But maybe that's the only way to do it. In buildings filled with nurses and wheelchairs, physical therapists and defibrillators, maybe it's best that I not know if S.'s cognitive abilities are slipping or if they will continue to slip. Maybe, all I can bring is the poetry and bring it how I've always brought it: in the moment, in the lovely, wild moment of connection that those spring afternoons grant us.

I'm reminded, finally, of a story Brad Lewis told the other night as we sat in on a round-table discussion about health and wellness with a group of NYU studentsaall of whom, brimming over with newly-discovered knowledge and wild hope for the future, are right around S.'s age. The story was of the Buddhist monk and the goblet. "You see this goblet?" The Buddhist said. "For me, it is already broken," and he lifted it to the sky and, then he drank from it. I imagine the water was sweet and cold but even if it was bitter I am certain that it was exactly what he needed.

The Craft of Writing: A Workshop for Doctors-in-training

September 9, 2007 at 5:55 pm

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004Commentary by Anna Reisman, M.D., Co-Director, Department of Internal Medicine Writers' Workshop, Yale University School of Medicine

In this blog, I'll tell you about a writing workshop for residents at Yale that centers on the craft of writing, and I'll argue that this focus has great value for doctors-in-training.

We created the Yale Internal Medicine Residency Writers' Workshop in 2003 to enhance residents' power of observation, provide a creative outlet, increase empathy, encourage reflection, and, through all of these, to combat burnout. The annual workshop runs for two full days each November and was led by Abraham Verghese in year 1 and Richard Selzer in years 2-4 (Selzer and I will co-run this year's workshop). The participants, mostly internal medicine residents with a smattering from psychiatry, pediatrics, and surgery, submit a piece of fiction or nonfiction prose. We spend a good portion of the time critiquing these manuscripts in detail. Unlike the writing that goes on in other residency programs and medical schools, where the idea is to set down one's thoughts and experiences in ordinary prose (i.e. journal entries, critical incident reports, parallel charts), our focus is on the writing itself: how to relate our experiences, and those of our patients (whether imagined or real), in clear, resonant, interesting, and lively prose. The Department sponsors a Grand Rounds on writing and medicine two months later, as well as a reading for faculty and residents and an annual publication called Capsules that is distributed widely. This year, we created sound files of some of the readings: (http://residency.med.yale.edu/writer.html )

In a study of the workshop, we found some of what we had expected: residents in focus groups reported a heightened awareness of patients' humanity and enhanced self-awareness. What we hadn't expected, and what we believe was one of the key ingredients to the workshop's success, was that the process of sharing writing created a unique camaraderie. The group bonded because everybody was similarly vulnerable.

Does a focus on the craft of writing make better doctors? Or does spontaneous, unpolished writing accomplish the same thing? I believe that there is a role for both in medical training. Informal writing - journal writing, for example - can be a very effective way to process our many often overwhelming experiences. Similarly, sessions devoted to writing critical incident reports can be a way to bring disturbing interactions (that might otherwise never see the light of day) to a discussion format with peers.

Taking the next step - finessing one of these unpolished pieces into a publishable piece of writing - is something else altogether. In the process of reworking the language, the rhythm, the images, the presentation of ideas, the writer must explore the experience more thoroughly in order to make the story logical and clear. For example, my own journal is a rich repository of experience but when I extract a section and prune and shape it into an essay or story, that is when I really start to understand its deeper meaning.

An emphasis on craft will, of course, appeal to a subset of residents who are interested in improving their creative writing skills. But shouldn't all physicians be able to write clearly? I believe that an opportunity to gain tools for expressing one's thoughts and beliefs in a variety of settings — whether writing a story, an opinion piece for a newspaper, or a research study — should not be missed. You can't go wrong with good writing skills.