Art in the art of medicine

When it comes to diagnosing what's wrong in a patient, medical schools are increasingly telling students to look for answers in unexpected places: in novels, paintings, dance and theatre, writes MIKE ANTON

TECHNICAL training remains the heart of medical education, but the number of future doctors taking literature, art interpretation and other humanities courses has surged over the past decade. They are trying to awaken their feelings and intuition as a way to connect with patients who often feel as though they've been reduced to a collection of symptoms.  

Educators say the distilled emotions and insight in the arts offer students a crash course in the old-fashioned skill of the bedside manner. Art, they say, is a textbook on the human condition.  

“What we are dealing with here is the art in the art of medicine,'' said Brownell Anderson, an executive with the Association of American Medical Colleges.  

COMPASSION: Every patient has a story, and a good doctor can pick up clues in a patient's personal history and emotions that could be causing his physical ailment.

This year, more than three out of four of medical schools offered humanities course work alongside such staples as molecular biology and neuroscience. In the early 1990s, only about one out of three did.  

Yale students study paintings at the university's Center for British Art to enhance their observational skills. At New York's Columbia University, trainees read Tolstoy's The Death of Ivan Ilych as a primer on suffering, and to sharpen their abilities to interview and listen. At the University of California, Irvine, anatomy students write essays about their cadavers, imagining who they were in life, before taking them apart.  

“The medical education system gives students the message that what's important is memorising textbooks,'' said Johanna Shapiro, a psychologist who started the medical humanities programme at UC Irvine five years ago. “To be a good doctor, they have to draw on every resource they have, including what's inside themselves. Science is simply not enough.''  

In the traditional boot-camp world of medical school – where students spend countless hours digesting scientific facts – the humanities were once seen as having nothing to do with treating the sick.  

“We talk tongue-in-cheek that when a student moves from his pre-med to his medical school years, he is moving from the pre-cynical to the cynical years,'' said Dr Abraham Verghese, an infectious-disease expert and best-selling author who last year began a medical humanities programme at the University of Texas, San Antonio.  


UC Irvine student David Santos, 26, found medical school left him no time to pursue his passion for painting. “It's been really hard to come back full circle and feel some of the creative juices I once had,'' he said. “Medical school dehumanises people.''  

Time was, a doctor might taste a patient's urine to denote its sweetness and confirm diabetes. But sophisticated diagnostic tests, tiny scopes and surgical tools and body scans have rendered such intimate techniques obsolete. Today, it's possible for a doctor to treat a patient without ever laying hands on him, or even looking him in the eye.  

Dr Irwin Braverman, who leads the art class at Yale's medical school, recalls a patient with unexplained tumours on his legs. A resident, told in advance what the complaint was, walked in and “saw a person, a blob, and he immediately looked at the legs,'' Braverman said. The tumours provided no clue as to their cause; a biopsy would only narrow the possibilities.  

Braverman saw something else. The patient had bulging eyes, which combined with the tumours, told him the man had thyroid disease.  

“Doctors rely more on technical imaging devices than the eye,'' Braverman said. But a 2001 study published in the Journal of the American Medical Association found students who studied paintings in his class were 2 1/2 times more likely to notice subtle diagnostic details in patient photos than students who hadn't taken the class.  


Narrative medicine 

In a 2001 Gallup poll of more than 45,000 US patients, respondents gave their doctors high marks for care and compassion, but significantly lower marks for communication skills.  

“They said, 'How can you diagnose me if you didn't give me a chance to talk and you didn't listen? And if I do tell you something, you interrupt me?' '' said Rick Blizzard, a health-care consultant who analysed the data. 

Doctors feel frustrated too.  

“The traditional rewards for medical practitioners have diminished. They don't make as much money as they once did; they don't have the status in the public's eye as they once did; they're hounded by clerks from the insurance company,'' said Dr Rita Charon, who teaches humanities at Columbia University's medical school.  

“Doctors are asking themselves, 'What are the real, fundamental rewards of taking care of sick people?' ''  

One answer, Charon said, is for medical schools to use the arts, particularly literature, to teach doctors how to engage sick people in a way that deepens their understanding of the patient, their illnesses and ultimately themselves.  

Charon was awarded a 2002 Guggenheim fellowship to continue her research into what she calls “narrative medicine'' – the way in which studying the emotions in literature can sharpen a medical student's ability to make a diagnosis by “reading a patient's story'' through observation, listening and expository writing.  

Charon writes up her notes from patients' visits in narrative form, then asks them to critique her version of their story and fill in the blanks. “Our traditional methods of diagnosis are good at picking up, say, anaemia,'' she said. “They're not very good at picking up clues in a patient's personal history and emotions that could be causing a physical ailment.''  


Medicine and literature 

The study of literature is the foundation of medical humanities, and for good reason. Medicine and literature have long been intertwined.  

Illness and suffering are the subject of countless classics. Anton Chekhov, Somerset Maugham, William Carlos Williams, Arthur Conan Doyle and Walker Percy all wrote novels informed by their training as physicians. William Osler, whose 1892 textbook The Principles and Practice of Medicine helped revolutionise its study, argued that prospective doctors should be as well-versed in literature as they are in science.  

But it was the 1910 publication of the Flexner Report, a Carnegie Foundation study, that had the greatest impact on how US doctors are trained. The report advocated the German model of tough admissions standards and an education steeped in the hard sciences. It's essentially the model used today.  

“The first two years of medical school is all about swallowing and memorising a tremendous amount of material that's boring and stultifying,'' said Richard Selzer, a former surgeon and Yale professor who has written 10 books, many based on his work in the operating room.  

“I'm not anti-science or anti-technology, but this emphasis on science has outstripped our ability as human beings to function in a humane way with patients. 


Revealing secrets 

In recent years, Selzer, 74, has been in demand as a guest lecturer at medical schools. His books – particularly the memoir Letters to a Young Doctor, in which he bares his emotions, fears and failures – are standard reading in medical humanities courses.  

Selzer hasn't always been so popular. When he was first published in the 1960s, only one US medical school taught humanities. He said colleagues kept their distance for years, believing he was “revealing secrets'' that swept away the pedestal of unchallenged authority on which physicians stood.  

“My colleagues would say, 'What's the matter with you? Why are you telling people what it feels like to lay open a body? What it feels like to fail on the operating table?' '' Selzer said. “The feeling was to take on that responsibility and try to save a life, one has to be anaesthesised from the heat of the event.''  

As recently as 25 years ago, a student's ability to get into medical school could be jeopardised if his or her undergraduate transcript showed too much interest in literature, writing or the humanities, the Association of American Medical College's (AAMC) Anderson said.  

Yet in the past five years, several literary journals have popped up in unexpected places, attached not to university English departments, but to their medical schools.  

The awareness also can be seen in the Medical College Admission Test, which the AAMC administers. Since 1991, the test has included an essay component to attract students with talents beyond mastery of chemistry and biology.  

In fact, many of the test's essay topics seem better suited to a philosophy major: Creative inspiration, rather than careful planning, often results in the solution to a problem. The more people rely on computers, the more people become alienated from one another. Violence is sometimes necessary to achieve social change.  

“Stories – that's how people make sense of what's happening to them when they get sick. They tell stories about themselves,'' said Dr Howard Brody, a family practice physician and professor at Michigan State's medical humanities programme. “Our ability as doctors to treat and heal is bound up in our ability to accurately perceive a patient's story. If you can't do that, you're working with one hand tied behind your back.'' – LAT-WP 

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