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Medical Education, Medicine and Literature, Medicine and Society, Mental Health, Patient Care

Using graphic art to understand the emotional aspects of disease

Using graphic art to understand the emotional aspects of disease

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When it comes to describing the feelings of hopelessness of depression, the fear and anxiety of having an operation or the unrelenting pain of a chronic condition, sometimes words are not enough. But, as some patients have discovered, art can be a powerful medium for portraying and translating these complex emotional experiences. Cartoons can also help future medical professionals empathize with patients and consider their experience from more than a clinical perspective.

An article published last week on the anthropology blog Teaching Culture explores the use of graphic art in medical anthropology courses. It takes its inspiration from Allie Brosh’s comic Hyperbole and a Half, in which she uses a crudely drawn figure to transport readers through the painful inertia and numbness of her depression. I stumbled upon this comic a few years ago when a dear friend was depressed. At the time, I didn’t understand how that could be or what that meant. Brosh’s bizarre, raw, and yes funny, comic resonated not only with what I saw my friend going through, but with my own experience, even though I was not depressed. It enabled me to empathize and to offer her support that was more relevant.

The article also describes a curriculum that incorporates “graphic pathographies” – graphic novels and comics about experiencing illness – into a course for pre-med students. The coursework “examines the multifaceted relations between biomedicine, culture, and the art of care, and places a special emphasis on how creative and humanistic approaches to illness and healing might enrich clinical practice.”

When I asked for his thoughts, Errol Ozdalga, MD, a professor of general medicine involved with the bedside medicine Stanford 25 initiative, commented:

Graphic art is an expression that is probably under-utilized. At Stanford, our guest services offers patients the chance to do guided imagery by expressing their feelings via drawing. Many physicians are unaware this service exists. It’s an opportunity to better understand our patients’ perspectives and promote the importance of connecting to patients among our students.

Previously: Engaging with art to improve clinical skills, Image of the week: a medical-focused manga comic and Stanford nurse’s whiteboard artistry brings cheer to patients, co-workers
Photo by Krystal T

Medicine and Literature, Patient Care, Podcasts, Stanford News

Abraham Verghese: “A saintliness in so many of my patients”

Abraham Verghese: "A saintliness in so many of my patients"

Verghese lookingThere’s a quiet dignity that envelopes Abraham Verghese, MD. You can imagine other authors whose books have scaled to the top to be taken with themselves, hardly humble, but that’s not the case here. When you get to know him, you realize he’s a man of great depth, with a wonderful soul and a deeply felt sense of humanity. When he talks about treating patients it’s with reverence (“There’s a saintliness I saw in so many of my patients,” he told me) – as if each time he crosses the threshold into a patient’s room he’s entering hallowed ground.

Verghese has written two searing works of nonfiction: My Own Country, a paean to the young men he treated for HIV-AIDS when it was just emerging as a human scourge, and The Tennis Partner, a loving eulogy to a best buddy whose life went off the rails. Then the blockbuster novel Cutting for Stone: atop the New York Times best seller list for two years and selling more than one million copies. It’s a sweeping tale of how time transforms family – jolting the reader from the first page, where a Roman Catholic nun gives birth to twins boys and dies on the operating table. I read it during the height of the global economic chaos in 2009 and was transported each evening, thankfully, to another world outside of monetary meltdowns and fiscal maelstrom.

In this 1:2:1 podcast, Verghese and I talk about time’s impact on medicine, novels and life. (Time is the theme of the current issue of Stanford Medicine magazine.) About life, he tells me, “There’s a poignancy to living because we won’t live forever… As John Irving says in one of his books, ‘Life is a terminal condition. It’s about to run out on all of us…’ There’s no exception to that. And I think, in a way, that’s what makes life so beautiful.”

This podcast is accompanied by a Q&A with Verghese in the magazine.

Previously: Stanford Medicine magazine reports on time’s intersection with health, Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED, Stanford’s Abraham Verghese honored as both author and healer, Abraham Verghese’s Cutting for Stone: Two years as a New York Times best seller and Abraham Verghese at Work: A New York Times profile
Photo by Jason Henry

Humor, Medicine and Literature, Research, Science

Can science journals have beautiful prose?

Can science journals have beautiful prose?

5331998702_2e6ab9e5e8_zScientific journals are not known for being scintillating or inspiring reading. But could they be? A recent article in Nature elaborated on an online discussion started by Stephen Heard, an ecologist at the University of New Brunswick.

In a guest post on the Tree of Life science blog, Heard argued that snappier, livelier writing could attract and retain more readers. “Style and beauty are not incompatible with scientific writing,” he wrote. Papers could appeal to undergraduates, science writers, politicians, and the public.

But is a journal really an appropriate outlet for such writing? Blogs and commentaries might be better mediums for creativity and literary flair, as research articles often must adhere to a more rigid format and provide detailed descriptions of materials, methods and results. Participants in the online discussion have pointed out that clarity and order have a beauty in themselves, the inexorable logic on display in the progression from hypothesis to data to results. Others worried that stylishness would make science research less accessible to non-native speakers of English. Some mentioned (and critiqued) the conventional idea that whimsy and humor cover up flawed science and detract from clarity. And many others praised the idea of incorporating pleasure along with function.

In the original piece, Heard suggested three reasons scientists don’t write beautifully more often:

It could be that writing beautifully in scientific papers is a bad idea, and we know it. Perhaps readers don’t respect scientists who resist the conventional turgidity of our writing form. I don’t think this is true, although I’m aware of no formal analysis.

Or it could be that beauty is a good idea, but well-meaning reviewers and editors squash it. In my paper I argue that beauty (like humour) can recruit readers to a paper and retain them as they read; but that reviewers and editors tend to resist its use. But again, there’s no formal analysis, so I was forced to make both halves of that argument via anecdote.

Or it could be we just don’t have a culture of appreciating, and working to produce, beauty in our writing. I think this is most of the explanation: it’s not that we are opposed to beauty as much as it doesn’t occur to us that scientific writing could aspire to it.

He sees three ways this could change: scientists can add some whimsy to their own writing, leave it in others’ writing when editing, and praise it when they see it. He exclaims:

Wouldn’t it be great if there was an award for the best scientific writing of the year? I don’t mean the best science – we have plenty of awards for that – but the best writing to appear in our primary literature. Such awards exist for lay science writing; if one existed for technical writing I’d be thrilled to make nominations and I’d volunteer to judge.

Heard keeps his own science blog, Scientist Sees Squirrel.

Photo by Ashley Campbell

Cardiovascular Medicine, Immunology, Medicine and Literature, Stanford News, Surgery

Stanford Medicine magazine’s big reads of 2014

Stanford Medicine magazine's big reads of 2014

brain attackThis year’s most-read Stanford Medicine magazine stories were all about the heart, surgery and the immune system – the themes of this year’s three issues. The top 10 (as determined by pageviews on our website):

Previously: Stanford Medicine magazine’s big reads of 2013 and Stanford Medicine magazine’s big reads of 2012
Illustration, from the article “Brain attack” in the Fall 2014 magazine issue, by Jeffrey Decoster

Medical Education, Medicine and Literature, Patient Care

Prescribing a story? Medicine meets literature in "narrative medicine"

Prescribing a story? Medicine meets literature in "narrative medicine"

woman reading bookIn the November issue of The Lancet, Chris Adrian, MD, postulates about what might be called “narrative medicine.” How do stories and poems alter our experience of caregiving, illness, and suffering? Does literature “help”?

Adrian, who is trained in both creative writing and medicine, thinks that artistic expressions of experience do bring something to clinical care, whether care is experienced on the giving or the receiving end. He also finds these benefits ineffable, impossible to quantify, study, or prove, and all the more powerful for it. He writes:

Lately I feel a strong, anxious conviction that writing and reading fiction and poetry might in fact execute some kind of alleviating change upon our suffering, even in the world of the hospital, upon that portion of our suffering related to illness and death. I can’t begin to argue logically or systematically how it actually does this. Accidentally or miraculously is about as far as I get when I try.

The reason literature, or perhaps art more generally, complements clinical practice is because it communicates in an entirely different language that speaks to different aspects of the human experience. Adrian ponders a line from W.H. Auden’s  “In Memory of W.B. Yeats,” which reads, “For poetry makes nothing happen…” and speculates:

…which is not by any means actually nothing, but instead a domain of activity so estranged from our degraded understanding of what human beings can do in the world that [Auden] had to call it Nothing to say what he meant.

Adrian, who is on faculty at the Columbia University Medical Center and an accomplished author, feels that medicine doesn’t train doctors how to interact with the less-scientific aspects of humans experiencing illness, injury, and suffering. There’s a gap or an absence in most medical care, and that’s where storytelling can step in. Columbia’s Program in Narrative Medicine, which originated in 2000, is dedicated to this idea. It draws participants from a vast array of fields, and inspired the International Network of Narrative Medicine. As its website states, “The care of the sick unfolds in stories. The effective practice of healthcare requires the ability to recognize, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence is a model for humane and effective medical practice.”

Storytelling in medicine isn’t just for medical practitioners to engage in. Adrian’s musing was inspired by a new book by Carol Levine, Living in the Land of Limbo: Fiction and Poetry about Family Caregiving, which collects the stories of family members who dedicate uncountable resources to caring for sick loved ones. Consider also the longstanding role of the hospital chaplain, and the recent proliferation of doulas, both of whom are specialized professionals who work “next-to” medicine, absorbing emotions, anxieties, and fears, and providing nurturance. And then, of course, there are the patients themselves, who in Adrian’s words might benefit from “art as a considered clinical intervention… very nearly like prescribing a story.”

Previously: Intersection of arts and medicine a benefit to both, report finds, Literature and medicine at life’s end, Thoughts on the arts and humanities in shaping a medical career and Physicians turn to books to better understand patients, selves
Photo by Alex

Aging, History, Medicine and Literature, Medicine and Society, Stanford News

Stanford humanities scholar examines "the youngest society on Earth"

Stanford humanities scholar examines "the youngest society on Earth"

Young and old faces Over the past decades, our society has undergone a process of “juvenescence” that, according to Stanford professor Robert Harrison, PhD, makes it the “youngest on Earth.” For the first time in human history, he says, “the young have become a model of emulation for the older population, rather than the other way around” (as quoted in Stanford Report). The post-war period “has unleashed extraordinary youthful energies in our species and represents one of the momentous revolutions in human cultural history.”

Harrison is a professor of Italian literature whose new book Juvenescence: A Cultural History of Our Age examines the cultural forces that have brought about this development. The term “juvenescence” draws on the biological concept of neoteny, or the retention of juvenile characteristics through adulthood. Harrison’s research spans literature, philosophy, and evolutionary science.

His basic argument is that “juvenescence” can refer to either a positive or a negative change, and it isn’t clear which more accurately describes our current situation. The positive sense is one of cultural rejuvenation, while the negative one denotes juvenilization. Harrison explains, citing examples from his book:

Rejuvenation is about recognizing heritage and legacy, and incorporating and re-appropriating historical perspective in the present – like the Founding Fathers did when they created a new nation by drawing on ancient models of republicanism and creatively retrieving many legacies of the past… Unlike rejuvenation, juvenilization is characterized by the loss of cultural memory and a shallowing of our historical age.

…I feel ambivalent about where we are culturally in this age of ours.  It is hard to say whether we are on the cusp of a wholesale rejuvenation of human culture or whether we are tumbling into a dangerous and irresponsible juvenility.

Several aspects of our society suggest juvenilization. Most citizens of the developed world today enjoy the luxury of remaining childishly innocent about what they operate, consume, and depend on in daily life, while “in terms of dress codes, mentality, lifestyles and marketing, the world that we live in is astonishingly youthful and in many respects infantile.” Our culture’s emphasis on innovation and change honors the youthful drive that brings renewal and progress, but, without firm roots in the stability and wisdom of older generations and longstanding institutions, this risks being a meaningless chase after novelty. Youth’s genius is a luxury that requires solid foundations.

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Events, Medicine and Literature, Stanford News

"Deconstructed Pain:" Medicine meets fine arts

"Deconstructed Pain:" Medicine meets fine arts

Gernod_Weis_Oel_auf_Leinwand_150x200_1995Stanford’s medical school is just steps away from Stanford’s arts corridor, home to the Cantor Art Museum and the newly opened Anderson Collection at Stanford. This proximity results in a cathartic intersection between the arts and medicine, a connection captured by two recent events sponsored by Stanford’s Medicine & the Muse Program in Medical Humanities and the Arts.

The first event featured doctors and medical students reading poems they had written that were inspired by the paintings in the Anderson Collection at Stanford. The poetry reading included a performance by Stanford’s Musicians in Residence, the St. Lawrence String Quartet.

The second event, a gallery talk titled Honoring the Ghosts, celebrated Veteran’s Day by exploring the relationship between war trauma and art, through the paintings of the late Frank Lobdell, a World War II veteran and Stanford emeritus professor. The gallery talk, the first to take place in the Anderson Collection at Stanford, was an interdisciplinary event sponsored by Medicine & the Muse, the Stanford Arts Institute and the Anderson Collection. The event drew an overflow crowd, including World War II Veteran Genero Felice, Stanford student veteran Steven Barg and his wife, Shannon, also a veteran and Stanford physican John Scandling, MD, who majored in art history as an undergraduate.

The talk was introduced by Alexandar Nemerov of Stanford’s Art & Art History Department. Nemerov’s father, Howard Nemerov, was a World War II veteran who wrote about his war experiences, eventually winning a Pulitzer Prize for poetry. The audience listened intently as Sarah Naftalis, a doctoral student in Art & Art History, described Lobdell’s horrific World War II experiences: Part of a liberating party for the concentration camps in Germany, Lobdell’s unit came upon a burned barn full of concentration camp victims the Nazis did not want to be freed.

That experience influenced Lobdell’s work, and indeed, he stated that he worked out his war trauma “on the canvas.”

War trauma was also explored in the art, poetry and music event, when Hans Steiner, MD, used Jackson Pollack’s Lucifer as inspiration for his poem dedicated to his relatives killed in World War II.

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Medical Education, Medicine and Literature

The book that made me go to medical school – and other good reads

The book that made me go to medical school - and other good reads

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Editor’s note: Over the last several months, numerous young Scope readers have inquired about which books they should be reading to prepare for a potential future in medicine. We asked medical student (and SMS-Unplugged contributor) Natalia Birgisson to offer some suggestions.

“In my business, you can lose big, but sometimes you win big, too.” So begins page 87 of the book that made me go to medical school. It was the summer after my freshman year of college and I was volunteering in an outpatient pediatric ward. In the span of a week, I had seen two babies die. A newborn died of complications from seizures right in front of me, and a two week old baby died of malnutrition as we watched him wither away in an incubator.

I couldn’t stand the feeling of being a part of a system that was cumbersome and ineffective, I couldn’t stand my heart breaking, and I wanted to want to be anything other than a doctor. I lay in bed the next day and looked around my rented tropical room for distraction. On the night table was a book left by the last guest, The Soul of Medicine: Tales from the Bedside by Sherwin Nuland, MD, and what I found in his collection of stories was solace, companionship, and hope. It is a compilation of stories, each chapter written by a doctor in a different specialty discussing his or her most memorable patient. If you’re interested in medicine, the reality of it, then I suggest taking Nuland up on his offer to glimpse the mark that medicine leaves on a doctor’s soul. I keep it next to my couch in case a lost friend ever happens upon it the way I did.

Mountains Beyond Mountains by Tracy Kidder was the next book that strongly influenced me. A detailed glimpse into the life story and accomplishments of Paul Farmer, MD, PhD, who not only serves as a role model for anyone interested in global health, but who has changed the world for the better in a tangible way. What I remember from this book is a short scene in which we learn that, at least during the time the journalist was shadowing him, Farmer saw his daughter only once a month. They say that part of a teenager’s angst is realizing that her parents are not perfect and being angry at them for their flaws. Well, Dr. Farmer, I’m still angry with you for missing out on your daughter’s childhood the way my dad did. And for the rest of my life, when I think about changing the world by saving peoples lives, it will be with the caveat of improving on the model that he lived by. Because to me, there’s no point in helping strangers if I’m hurting the ones I love.

Blue Collar, Blue Scrubs and Hot Lights, Cold Steel by Michael J. Collins, MD, were two medical memoirs that resonated strongly with me. I read these the summer that I was writing my medical school applications. Somehow, the application process has a way of making everyone feel incompetent or mediocre at best. And here was a guy who decided to take post-bachelor classes as a construction worker, carpool to medical school, and marry the love of his life before starting residency at the Mayo Clinic. Almost every page of his books had me laughing or crying as I rooted for him.

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Events, Medicine and Literature, Stanford News

For group of Stanford doctors, writing helps them "make sense" of their experiences

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At a Stanford Pegasus Physician Writers Forum last week, psychiatrist Shaili Jain, MD, told the 40-or-so attendees that writing and practicing medicine are synergistic. Medicine and motherhood: not so much.

“As one of my mentors once said, it’s called ‘juggling the joy,'” Jain said. “People who don’t think it’s a challenge are either in denial – or someone else is doing all the hard work.”

Jain was one of five authors who shared their work. She read an essay, called “The Trimesters,” that she had written ten years earlier about her initial struggles coping with her duel roles as doctor and to-be mother. During her pregnancy, Jain suffered from intense all-day sickness. “Panic set in; was this what life was going to be from now on? I feared I had entered a no-man’s land of perpetual dissatisfaction,” Jain wrote. She had to tell her patients, some who suffered from severe mental disorders, she would be off work — a situation that left her uncomfortable with the blurring of roles. Pregnancy was personal, yet it impinged on her professional life.

Yet patients have no choice but to share their inner secrets, fears, goals, what medical school alum Ward Trueblood, MD, called their “heart songs” in the poem, “Cancer Doctor.”

It started when he slowed
to ask about a grandson’s picture
or fetched a cup of ice
for the bed-bound, listened to
talk of a fishing hole, heard about a dog
that licked a woman’s morning eyes…

They were sharing heart
songs rarely whispered.
He grew softer, invited
in this open window
of each one’s brave longing.

Medicine is a privilege, Trueblood went on to say. “As a cancer doctor, one shares soul with their patients… so here I am, 76, and I’m still going into the hospital,” he said.

And for Jain, writing is an essential part of her job as a physician. “I have a compulsion to make sense of what I’m experiencing,” she said.

The Pegasus Physicians Writers group meets regularly.

Becky Bach is a former park ranger who now spends her time writing about science or practicing yoga. She is an intern at the Office of Communications and Public Affairs. 

Previously: On death and dying: A discussion of “giving news that no family members want to hearWhen death comes rapping at the chamber door: Writers inspired by crises and medical emergencies and “How cancer becomes us”: A conversation with author and anthropologist Lochlann Jain
Photo by annazuc

Events, Medicine and Literature, Medicine and Society, Patient Care, Stanford News

Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED

Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED

Abraham Verghese TEMED

Few of us pay close attention to metaphors used in the language of medicine. Instead, our focus is typically on words relating to symptoms, test results and diagnoses. But as Stanford physician and author Abraham Verghese, MD, explained last week at TEDMED in San Francisco (which was co-sponsored by Stanford Medicine), metaphors, particularly as they relate to medicine, are significant because “they explain our past… [and] share our present and, perhaps most importantly, the metaphors we pick predicate our future.”

Verghese took conference attendees through a “grand romp through medicine and metaphor” during a session titled “Stealing Smart,” which featured seven speakers and their stories on how stealing something from another field, such as the principles of video game design, could improve medicine. As a child with “no head for math,” Verghese was drawn to the written word and developed a love for metaphors. His physical and metaphorical journey into medicine originated with his childhood reading and, as he sheepishly admitted, his reading list “had a certain prurient bias.” In fact, he selected the novel that set the course of his life, Of Human Bondage by W. Somerset Maugham, because the title “had great promise.” Despite it’s lack of salacious content, the book made a lasting impression on Verghese.

He recalled reading about how the protagonist, a boy named Philip who was born with a clubfoot, overcame great adversity to become a physician. The character was intrigued at the variety of patients he meets in the wards of the hospital and marvels at their willingness to open up about their personal lives at a time of distress. In describing the doctor-patient relationship, the author writes, “There was humanity there in the rough.” Those words spoke deeply to young Verghese and “implied to [him] that not everyone could be a brilliant engineer, could be a brilliant artist, but anybody with a curiosity about the human condition, with a willingness to work hard, with an empathy for their fellow human being could become a great physician.” He added, “I came into [the profession] with the sense that medicine was a romantic passionate pursuit. I haven’t stopped feeling that way, and for someone who loved words anatomy was such fun.”

Verghese reveled in the abundance of medical metaphors throughout his training. The prevailing metaphor in anatomy was that of a house, while the overarching metaphor of physiology was that of a machine. When it came to describing symptoms, there was no shortage of metaphors: the “strawberry tongue” associated with scarlet fever, the “peau d’orange” appearance of the breast in breast cancer and the “apple-core” lesion of colon cancer. “That’s just the fruits – don’t get me started on the non-vegetarian stuff,” he joked.

But all of the metaphors noted in his talk are 60-100 years old, and when it came to naming one from more recent times Verghese was at a loss. He said:

In my lifetime, and I suspect in yours, we’ve seen so many new diseases – AIDS, SARS, Ebola, Lyme… We have so many new ways at looking inside the body and scanning the body, such as PET and MRI, and yet, strangely, not one new metaphor, that I can think of… It’s a strange paucity because we are so imaginative. The amount of science that has been done in the last 10 years eclipses anything that was done in the last 100 years. We’re not lacking in imagination, but we may be lacking in metaphorical imagination.

This dearth of metaphor has two consequences, he said. The first is that Congress isn’t funding biomedical research to the level that is necessary to advance new discoveries and treatments. The second is that patients are “not as enamored with our medicine and our science as we might think they should be,” he said. Verghese implored the audience to “create metaphors befitting our wonderful era discovery.” He encouraged those in the crowd and watching the livestream online to accept this challenge, saying, “I want to invite you to name things after yourself. Go ahead! Why not?”

As he closed the talk, Verghese shared the metaphor that has guided his life by saying:

It’s the metaphor of a calling. It’s the metaphor of a ministry of healing. It’s the metaphor of the great privilege we’re allowed, all of us with anything to do with health care, the privilege of being allowed into people’s lives when they are at their most vulnerable. It’s very much about the art of medicine. And we have to bring all the great science, all the big data, all the wonderful things that we’re going to be talking about [at this conference] to bear one human being to another… We have to love the sick. Each and everyone of them as if they were our own. And you know what? They are our own, because we are all humanity there in the rough.

Previously: Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine, Inside Abraham Verghese’s bag, a collection of stories and Stanford’s Abraham Verghese honored as both author and healer

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