What "The Literature, Arts, and Medicine Database" Is and How to Use It

Resource for a New Paradigm in Training Doctors

By Felice Aull

(About the Author)

Felice Aull, PhD
Felice Aull, PhD

[This article was originally published in The Write Place At the Write Time (Summer 2012, www.thewriteplaceatthewritetime.org) and is reproduced here by their permission as well as that of the author.]

Introduction

Doctors traditionally have been taught that their interactions with patients should be strictly objective, concerned but detached. This view is currently being challenged with an emerging new paradigm. In this new model, engagement - emotional and intellectual - is valued and encouraged. Understanding the context in which individual illness occurs, and the meaning of illness in a person's life-world are recognized as being necessary for accurate diagnosis and successful treatment. It is increasingly understood that healthcare workers must be aware of their biases and preconceptions to avoid making judgment errors, and that they must deal creatively with the ambiguities inherent in their work. When working with patients, they must also be aware of their own fears and anxieties and learn to develop emotional resilience. One could say therefore that a paradigm of detached concern is being replaced by one of engagement, affiliation, reflective practice, and emotional resilience (for articles and books that discuss these concepts see references 1-5).

As educators develop methods to teach and promulgate the new paradigm for healthcare practice, literature and the arts are increasingly being enlisted in this endeavor. This essay will describe the background for this development, and then discuss the founding and use of a key resource, The Literature, Arts, and Medicine Database, which is the major component of the NYU Medical Humanities website. I will also reference relevant essays from the Literature, Arts, and Medicine blog site.

An Interdisciplinary Field

The centrality of story in the medical encounter has long been acknowledged.  In the 1960s a field of scholarship and teaching developed - Literature and Medicine -that uses precepts of literary analysis and focuses on a range of literature relevant to the illness experience. This field officially became an academic discipline in 1972 when a professor of English literature, Joanne Trautmann [Banks], was appointed to the faculty of a medical school (Pennsylvania State University College of Medicine). By 1995, at least one third of US medical schools offered courses in literature and medicine and in 2012 most medical schools in this country either require or offer as electives, courses that incorporate literature, film, and art to address the many facets of illness experience and of caregiver experience that are outside the field of medical science. To reflect the expansion beyond just literature to include other humanities, visual and performing arts, and social sciences as they are brought to bear on healthcare training, the term, 'Medical Humanities', came into common use. Although this field originated in the USA, its interface with healthcare education has spread to many other countries – even as far away as Nepal! (see "Medical Humanities: Sowing the Seeds in the Himalayan Country of Nepal."

While it is still relatively rare to find humanities scholars on the faculty of medical schools, increasingly there is collaboration and consultation between arts and sciences and medical school campuses, and some medical schools have appointed "artists in residence" and "writers in residence." Outside of the education setting, Literature and Medicine has entered community hospitals. For example, The Maine Humanities Council initiated a national reading and discussion program for hospital-based staff, "Literature & Medicine: Humanities at the Heart of Healthcare." This program has reached at least 25 states in the US.

Story and Medicine

Fiction, memoir, poetry, and other genres often bring powerful stories to readers. These genres engage the emotions and expose readers to worlds outside their own experience. Such worlds may be those of illness or caregiving, but may also highlight issues of ethnicity, gender, power relations, socioeconomic status, etc. Literature requires us to attend to plot, relationship between characters, language, metaphor, gaps in the narrative. "Literature teaches us in unique ways to imagine the other, to use the imagination as an instrument of compassion, to tolerate ambiguity, to dwell in paradox, to consider multiple points of view." (6) There is usually no single "correct answer" in its interpretation. Notes physician-writer Jay Baruch, who recently helped develop "Integrated Clinical Arts," a required medical humanities curriculum at Brown University's medical school: "reductionist thinking" is pervasive in medical education but "the challenge in medicine is dealing with messiness and nuance." (7)

During the last 10 years, the turn to narrative has had a large impact on medical humanities, pioneered by Rita Charon, who is trained in both medicine and literature. She coined the term "narrative medicine" and her Narrative Medicine Program at Columbia University College of Physicians and Surgeons trains others to teach and practice this approach to healthcare education. (8) A faculty member on her team, Maura Spiegel, writes, "A premise of Narrative Medicine is that attentiveness to how stories are told can make you better at considering a patient's story -or another caregiver's story or your own. It can help you identify what pieces of the story might be missing, what more you'd like to know, or what doesn't seem to fit. Notice[ing] where a story begins and ends, who's included in the story, whether or not it runs along a familiar plot line, how the teller's affect changes in the course of the telling." ("Teaching Film: A Perspective From Narrative Medicine." )

Arts and Medicine

Visual arts have more recently entered medical humanities training. Often the focus is on developing better observational and interpretive skills, but also recognized is the power of visual arts to elicit an emotional response in the observer. Bringing all of these together is the goal of numerous art-and-medicine classes, which often take place in museums and may be led by museum educators or those trained by museum educators. For example, Florence Gelo, faculty at Drexel University College of Medicine, describes how she brings doctors in a Family Medicine residency training program to Philadelphia art museums and encourages them to describe to each other their emotional responses to a painting, to notice details, to interpret. See annotation of "The HeART of Empathy: Using the Visual Arts in Medical Education" and its accompanying online video in the Literature, Arts, and Medicine Database.

Performing arts, particularly film and television series, are commonly part of a medical humanities curriculum. Film clips are popular in medical ethics classes, and full-length films that provide insight into the history of medicine are common. Consideration of full-length films can proceed in a way similar to consideration of literary works, emphasizing either topical content or narrative analysis. Maura Spiegel, who teaches both literature and film in the Narrative Medicine Program at Columbia, writes about teaching the film, "The Doctor" from both a "topical" and a "narrative" perspective. Her blog essay is well worth reading ("Teaching Film: A Perspective From Narrative Medicine"). For further discussion of use of film and theater in medical humanities, see references 9 and 10, respectively.

Expressive Arts and Medicine

Medical Humanities is now bringing the active arts into curricula and programs. Drawing, as well as creative and reflective writing have been incorporated into optional or required healthcare training. These provide opportunities for creative expression and foster observation and self-analysis. Often they are group activities whose creative products are shared and discussed among participants. Sessions may be led by professional artists and writers. See, for example, the description of a craft of writing workshop at Yale University School of Medicine (Anna Reisman. "The Craft of Writing: A Workshop for Doctors- in- training" ) and an essay on how a creative writing project for doctors in Nebraska provides professional inspiration and prevents burnout (Steve Langan. "The Seven Doctors Project: Creative Writing As Inspiration And Intervention.

Reflective writing is a required curricular element in some medical schools. Students and resident physicians may be asked to write a reflective, self-analytic piece about an experience with a patient or patient's family. Poetry may be a form of expression in certain programs. Johanna Shapiro, Director of the Medical Humanities Program at University of California Irvine School of Medicine, collected and analyzed more than 500 poems by medical students from different institutions. She developed categories that describe what students expressed in their poems. Among these were chaos, journey, and witnessing. (11)

At New York University School of Medicine, artist Laura Ferguson teaches anatomy drawing to interested students and works on her own drawings as she observes dissections in the student anatomy lab and incorporates 3-D images of her own body into her work.  A Family Medicine residency program at McGill University offers trainees an interdisciplinary art project, to fulfill a research requirement. Participants are expected to meet specific goals within stated learning objectives. They have created films, sculpture, poetry, and other products. (See blog essay by the project's creator, Dr. Maureen Rappaport, "Interdisciplinary Arts Project in a Family Medicine Residency Training Program."

Performance studies methodology is currently under consideration to help teach students and physicians "how to interact with patients in a compassionate and empathetic manner . . . Performance studies offers a paradigm for teaching doctors to identify and critique the professional roles that they play daily and to choose their words and gestures deliberately so that their interactions with patients become more empathetic, compassionate, and thoughtful." (12)

The Literature, Arts, and Medicine Database: Development and Uses

Literature and medicine as a field for healthcare training was beginning to take hold in the early 1990s but there were few resources for instructors. Widely used at the time was an annotated bibliography by the pioneering scholar, Joanne Trautmann [Banks]. (14) First published in 1978 and last revised in 1982, it was no longer up to date in the early 90's. The early 90s was also the period when the World Wide Web was introduced and coming into widespread use.

I had started to use literature in seminars with pre-medical and medical students at NYU, exploring the illness experience and experiences of doctors-in-training. As I attended workshops and professional meetings where such teaching was discussed, an idea germinated: those teaching literature and medicine could combine forces and together contribute to a Web-based annotated bibliography. We (NYU) would make this available on the Internet freely so that those interested would have easy access, and so that the field might be promoted and spread. Multiple contributors from different institutions and with varied interests would bring a range of perspectives and literary works. The Web format allows for frequent updates so that the material could be kept current. So, in 1993 the Literature and Medicine Database was established at NYU with four of us in the initial group of editor- annotators. Gradually I recruited additional individuals, resulting in approximately 20 editor-annotators from all over North America. Some have left the project and new ones have joined, but turnover is low. As the field developed to include art and film, the database expanded to include those genres as well.

Currently the Database holds more than 2500 annotations, primarily in literary genres, but also several hundred in art and film. It is searchable by keyword, genre, author, and several other categories as well as with an internal Google search engine that can search for any word or phrase (Free Text Search). There are extensive internal hyperlinks (cross-referencing) and links to external online texts, artworks, film trailers, author and artist homepages. The site gets more than 4000 page views per day and is used to create courses in medical humanities; by students at all levels - graduate, undergraduate, high-school, medical, nursing--for thesis and other academic work; by scholars and writers doing research; by patients and reading groups; by libraries; and by others.

The Search and Examples

How might a user find annotations for a specific purpose, and what might be found? One way to get started is to view the list of keywords, in order to see the topics covered in the database, or to get ideas for course topics, essay topics, etc. Database topics are, however, not confined to those listed as keywords – many other themes are included and can be searched for with the Google engine. Having picked a topic, the user might then decide to limit the search, for example, to poems or short stories, or to art. Perhaps the user wants only to read annotations with online links to the text or art in question. Below are six examples of searches, with highlights of the results.

1. Keyword: Patient Experience  Genre: Poem

This search can be done quickly with the "Annotation Search" function, which has a pull-down menu for all the literary genres in the database. The results can be sorted by title or by author; both are displayed. More than 100 results are available – I choose the annotation of L. E. Sissman's poem, "Homage to Clotho: A Hospital Suite."

Writes the annotator, "Keen observation and carefully clever metaphors make poetry his best defense against his own impending death from Hodgkin’s disease." "Empathy is a major theme of the poem."

2. Keyword: Doctor-Patient Relationship  Genre: Poem  Additional feature: on-line text of poem

Since there are now three search criteria, an internal Google search (Free Text Search) of linked terms is best. A search for doctor-patient AND poem AND on-line yields as the first result, "The Distant Moon" by Rafael Campo.

 

In this case the search result link is to the audio and text of Campo's own commentary and reading, which are linked to the annotation. Campo tells us that the poem is about a patient he had and "how much our patients actually care for us  . . ." The annotator notes that the poem is "a fine evocation of the tension between clinical distance and emotional attachment." (One can find the annotation using Annotation Search for the title, or from the Author list to see the works by that author annotated in the database.)

3. Keyword: Illness and the Family Genre: Poem Additional feature: on-line

The free text search yields annotations of more than 30 poems. Suppose we select the annotation of Tony Hoagland's poem, "Lucky," about caring for his dying mother. The annotator notes that "this is caregiving with a twist – the mother is likened to a weakened enemy". The poem is "deeply unsettling" but brings out the conflicting emotions in such a situation. Other works that could be compared with the poem are suggested. Hoagland's audio commentary, reading, and text are linked to the annotation.

4. Keyword: Cross-Cultural Issues Genre: Short Story

Using the Annotation Search function, more than 25 results are displayed. Selecting Toni Morrison's story, "Recitatif," we learn that "The story is a wonderful classroom tool for discussing stereotypes of embodied differences like race, class, and disability."

5. Keyword: Power Relations Art, on-line

With Free Text Search we find an annotation of the painting by Degas, "Interior." The annotator writes, "Degas' brilliant rendering of perspective pulls the viewer into the mystery of what has taken place/is taking place in this room. We don't know how to look at this scene, much less how to interpret it." "The human drive to narrativize and seek meaning in what is seen (and experienced) can lead to misinterpretation." Other paintings of psychological exploration and social commentary are mentioned and an article that discusses the painting is referenced.

6. Keyword: Physician Experience Film

The Son's Room. This film, concerns the death of a psychoanalyst's young son. The annotator writes: "We, the audience, need to process our own loss of the character and our identification with Giovanni’s grief, and instead we are forced, with him, to listen to the anxieties of his patients, which suddenly seem almost outrageously petty and selfish. The challenges of empathy and of professionalism in the face of personal agony has surely seldom been so vividly presented."

The above annotations discuss topic but also comment on form and narrative approach.

There are several database annotations of works that focus on activities, for example Gillie Bolton's books, Reflective Practice: Writing and Professional Development and The Therapeutic Potential of Creative Writing: Writing Myself.

And now, please browse and search the Database!

References

  1. Coulehan, John L. “Tenderness and Steadiness: Emotions in Clinical Practice.” Literature and Medicine. 14/2, Fall: 222-236 (1995).
  2. Coulehan, Jack. “Empathy, Passion, Imagination: A Medical Triptych.” Journal of Medical Humanities. 18/2 , Summer 99-110 (1997).
  3. Charon, Rita. "Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust." Journal of the American Medical Association. 286: 1897-1902 (2001).
  4. Charon, Rita. "Narrative Medicine: Attention, Representation, Affiliation." Narrative. 13/3: 261-270 (2005).
  5. Halpern, Jodi. From Detached Concern to Empathy: Humanizing Medical Practice.  (New York: Oxford University Press) 2001.
  6. Hawkins, Anne Hunsaker.  Teaching Literature and Medicine, eds. Hawkins, Anne Hunsaker and Marilyn McEntyre. (New York:  Modern Language Association 2000), 14.
  7. Cambra, Kris and Delpoio, David. "Think Different: an integrated humanities curriculum teaches medical students new ways of seeing." Brown Medicine Magazine, Winter, 2012 cover story, p.2. <http://brownmedicinemagazine.org/past_issues.php> Accessed  May 23, 2012.
  8. Charon, Rita. Narrative Medicine: Honoring the Stories of Illness. (New York: Oxford University Press) 2006.
  9. Editors Colt, Henri G., Quadrelli, Silvia and Friedman, Lester D., eds. The Picture of Health: Medical Ethics and The Movies. (New York: Oxford University Press) 2011.
  10. Belli. Angela. Bodies and Barriers: Dramas of Dis-Ease. (Kent, Ohio: Kent State University Press, Literature and Medicine Series) 2008.
  11. Shapiro, Johanna. The Inner World of Medical Students: Listening to Their Voices in Poetry. (Abingdon, UK and New York: Radcliiffe Publishing Ltd.) 2009.
  12. Case, Gretchen A. and Brauner, Daniel J. "The Doctor as Performer: A Proposal for Change Based on a Performance Studies Paradigm." Academic Medicine.  85(1), January 2010, pp 159-163.
  13. Martin Kohn. "Performing medicine: the role of theatre in medical education." Medical Humanities. 37:3-4 (2011).
  14. Trautmann, Joanne and Pollard, Carol. Literature and Medicine: An Annotated Bibliography. (Pittsburgh: University of Pittsburgh Press) 1978, 1982.