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Reclaiming Reflection: Creative Writing and the Medical Humanities (1)

14 Sep, 16 | by cquigley

 

Poetry and Reflection: a powerful tool for learning

This post is part of a series over the next three days on the theme of Creative Writing and Medical Humanities by Dr Eleanor Holmes (pen name Eliot North).

 

 As a GP Tutor I’ve delivered seminars on the patient centred medicine (PCM) component of Newcastle University’s Medical Undergraduate (MBBS) course to 1st and 2nd year students, for the past three years. Professional reflective practice is taught and assessed across all five years of the curriculum.

The ability to reflect and learn from clinical encounters is central to medical education and continuing professional development. Delivered within a creative context, I believe written reflection can also be an important tool to foster wellbeing and resilience in healthcare students and professionals.

Working in an increasingly overstretched and under resourced system such as the NHS, in which clinician burnout and mental health problems are on the rise, the question of how we reflect on the difficult and complex nature of care is becoming ever more important to address.

Stating that the answer might be found outwith Medicine may seem heretical, but it is my belief that we need to look outwards to move forwards. The Arts and Humanities, like Health and Medicine, explore and reflect upon the human condition. What therefore can we learn from each other?

My last seminar with my first year group was entitled ‘Professional Reflective Practice 2.’ After a year of working together trust, an essential element of clinical reflection, had been built within the group. I used my own writing, a poem called He Blew Me a Kiss, as a launch point for discussion, which was published under my pen name Eliot North.

 

            He Blew Me a Kiss

 

She liked Frank, they connected

despite his expressionless face. Behind the wound-up limbs and tremor

a gentle man shone out from the mask.

 

When she visited they would share a cuppa,

chat about this and that. Do the ‘medication shuffle’;

a two-step dance they both knew well.

 

She’d heard about stem cell research.

How they’d taken swabs from patients’ skin. Growing stem cells

from skin cells in dishes, right there in the lab up the road.

 

These stem cells would then become brain cells.

Models of Parkinson’s just like Frank’s. For testing newer and better

medications and perhaps one day even a cure.

 

The last time she saw Frank it was snowing

but he insisted on accompanying her out. Standing by the gate like a sentinel

he’d wave her off that one last time.

 

Later she’d think of stem cells like kisses

blown on the winter air. The moment captured in her rear-view mirror;

A hand lifted slowly, toward a frozen face.

 

Published by EuroStemCell ‘Tales from Within: Imaginative Non-Fiction on Stem Cells,’ 2013. (Frank is a pseudonym)

http://www.eurostemcell.org/he-blew-me-kiss-eliot-north

 

I have found that reading a poem aloud, that I’ve written myself, is an extremely powerful learning tool. There are obvious medical elements I can draw out regarding Parkinson’s Disease and stem cell research, but more than that the poem makes an important statement about connectedness, communication, the complex and varied role of a doctor as well as the limitations of medical science. It speaks to students about the importance of getting to know patients and continuity of care; how embracing the humanity in an encounter can be both powerful and revelatory.

The moment captured in the poem will live with me until the day I die, reading it always chokes me up; I choose to show this emotion to my students. We as clinicians who teach, whether in seminars or on the wards and in clinics, are hugely powerful role models. By stating and showing that this encounter moved me I am by example saying, “It’s OK to show emotion.” This leads to discussions about professionalism, boundaries and clinician wellbeing linked to the evidence base that demonstrates better patient outcomes when doctors show that they are emotionally affected when breaking bad news.

I wrote this poem many years after the event, it was something that sat in my brain waiting to come out. I wish that I’d been able to share it with the man who inspired the poem but he died some years before I got it down on paper. It was a EuroStemCell competition, partnered with the Centre for Regenerative Medicine in Edinburgh that spurred me to write it.

The challenge to submit an ‘imaginative non-fiction’ poem that incorporated stem cell research brought this encounter immediately to mind, the link between stem cells and Parkinson’s a way to explore how I felt about this patient. Discussing the creative process and the fact that I write under a pen name and changed the patient’s name forms a nice link to the importance of anonymity, confidentiality and consent, as well as patient and doctor voice.

With my students I then facilitated a creative guided writing exercise on a memorable clinical encounter followed by small group work, drawing and writing Haiku. The seminar culminated in poster presentations delivered by the students to the group. The results were insightful, empathetic and moving; their use of metaphor and close observation giving authenticity to the explorations they had made of encounters with patients and carers struggling to cope with dementia, a potential diagnosis of cancer and the communication difficulties witnessed for a patient with learning disabilities, linking this to issues of capacity and consent.

As someone who uses creative outlets as a way of coping with the stresses of practicing medicine, it amazes me that the word ‘creative’ can strike fear in to the hearts of medical students and healthcare professionals alike. I believe that by embracing creativity and essentially our inner child, written reflection can be much more than a required component of assessment and appraisal. All humans have the capacity to be creative, no matter how much they protest to the contrary. The skill lies in being able to coax it out of them.

 

Acknowledgements

All of the work I’m currently doing in this area is in collaboration with Sue Spencer with whom I wrote the guided writing framework I used above with my students, influenced by reading the books and on-line resources below. We are delivering a ‘Reflection of Clinical Encounters’ workshop using creative writing methodologies in November 2016 for the Staff Development Programme, School of Medical Education, Newcastle University.

Writing Poems by Peter Sansom, Bloodaxe 1994

The Poetry Toolkit – The Poetry Trust 2010, available as a free PDF download http://www.thepoetrytrust.org/images/uploads/pdfs/Toolkit%20for%20Teachers.pdf

 

Related reading

S E Gull, R O’Flynn, J Y L Hunter. Creative writing workshops for medical education: learning from a pilot study with hospital staff. Med Humanities 2002;28:2 102104

Khaled KarkabiOrit Cohen Castel. Teaching reflective competence in medical education using paintings. Med Humanities 2011;37:1 5859

T J Collett, J C McLachlan. Evaluating a poetry workshop in medical education. Med Humanities 2006;32:1 5964

The Reading Room: ‘Making Medical Knowledge’

25 Apr, 16 | by cquigley

 

Making Medical Knowledge

By Miriam Solomon

Oxford University Press, 2015

 

Reviewed by Dr Jonathan Fuller, University of Toronto

 

We should forgive anyone unfamiliar with recent trends in ‘scientific medicine’ for thinking that within scientific medicine there are now multiple medicines to choose from: evidence-based medicine (EBM), translational medicine, narrative medicine, personalized medicine, and so forth. These approaches are not distinct professions in the same sense as allopathic medicine and naturopathy. But just what are the relationships among modern medicines many ‘medicines’?

In Making Medical Knowledge [1], philosopher Miriam Solomon sets out to assess four of these movements introduced over the last forty years: medical consensus conferences, EBM, translational medicine, and narrative medicine. She calls them ‘methods’ to be concise, but notes that they are distinct epistemological approaches, or approaches to (medical) knowledge. Solomon writes that she selected these four methods because of their “dual and paradoxical epistemic character” (p. 14): there is something obvious about each of them (of course medicine should be ‘based on evidence’), as well as something odd (‘evidence-based medicine’ deemphasizes many kinds of evidence, including expert consensus). Given how much time, effort and money is being spent in the name of these movements, a close inspection is certainly warranted.

Solomon’s approach in her book is to examine these methods using an interdisciplinary lens. She situates her study in the realms of social epistemology, philosophy of medicine, integrated history and philosophy of science, science and technology studies (STS), and critical medical studies. She describes her approach as “Naturalistic, Normative, Applied, Pluralist, Social Epistemology” (p. 11); in other words, she aims to describe and evaluate actual medical knowledge and practice using a diverse set of tools, and with a focus on the social. She writes for a broad academic audience, including the medical community.

In the introductory chapter, Solomon argues that “[t]he science/art dichotomy is no longer a fruitful disciplinary divide” or a meaningful way of describing medicine (p. 11). She instead argues that a ‘methodological pluralism’ describes contemporary medicine and its many methods for negotiating knowledge. Solomon then spends three chapters examining medical consensus conferences and group process, two chapters on EBM, one chapter on translational medicine, and one chapter on narrative medicine. The penultimate chapter advances Solomon’s ‘developing, untidy, methodological pluralism’. According to this view, medicine’s epistemological approaches do not have exclusive domains of application; all of the methods she describes are in active use, their domains overlap, they sometimes come into conflict with one another, and there is no “hierarchy of methods” (p. 229) to rescue us when they clash. The final chapter summarizes Solomon’s main conclusions.

Making Medical Knowledge is an excellent and pioneering study of some of the dominant movements in early Twenty-First Century medicine, which – with the exception of EBM – are relatively unexplored by scholars. It provides a good entry point, offering detailed and insightful reconstructions of each method within its historical context, thus satisfying Solomon’s descriptive aim. The historical detail is rich, especially for medical consensus conferences. Solomon is charitable towards each method, and manages to find substance amidst the rhetoric, even for translational medicine, which is especially difficult to pin down and appears at first glance to offer no more than metaphor. She also provides thoughtful criticisms of each method, thus satisfying her normative aim.

Overall, I think Solomon pitches the discussion well for the broad audience she has in mind. The philosopher, historian, sociologist and anthropologist should all find something of interest in her book. I expect that clinicians, especially within academic medicine, will find it fairly accessible. Satisfying the needs of her diverse audience perhaps prohibits Solomon from going into as much depth as some philosophers, historians or social scientists might like. Such is the cost of interdisciplinarity, but it pays off in the form of a study that benefits from its use of multiple disciplinary lenses.

While I generally agree with Solomon’s analysis of each method, I was not fully convinced that an ‘untidy, methodological pluralism’ is the best way to understand the relationships among the methods. Solomon accepts that the methods are often active at different stages of research, but nonetheless argues that they do not fall on a “tidy linear spectrum” from research to practice (p. 206). Yet as her own analysis reveals, translational medicine (research from ‘bench to market’, or ‘T1’) refers to basic medical science research as well as Phase I and II clinical trials, EBM appraises and aggregates the results of Phase III trials, medical consensus conferences make therapeutic recommendations based on the results of Phase III trials or systematic reviews of trials, and narrative medicine (in its integrated form) interprets guidelines and the research literature in the context of the patient’s story. In other words, translational medicine applies to medical research, consensus conferences apply to knowledge dissemination, and EBM and narrative medicine apply to clinical practice. The main purpose towards which each method is put is unique: translational medicine develops new medical technologies, consensus conferences develop consensus statements or clinical guidelines (often pertaining to those technologies), EBM appraises evidence and applies it in clinical practice, and narrative medicine uses narrative techniques at the bedside. Thus, their domains are less overlapping and arranged more linearly than Solomon’s untidy pluralism might suggest.

Of course, the practice of EBM might sometimes conflict with the practice of narrative medicine (more on this point in a moment). Moreover, the practice of narrative medicine or of EBM might sometimes conflict with the products of consensus conferences: clinical guidelines. Narrative medicine locates individuality in the patient’s narrative, and EBM is often defined as the use of evidence in the care of individual patients [2]. On the other hand, guidelines make recommendations for broad groups of patients, not for individuals.

Solomon presents the example of breast cancer screening for women in their forties to illustrate the various ways that the methods can clash with one another. However, most of the conflict that Solomon describes occurs within each method: among pathophysiologic theories of breast tumour development, among primary studies and systematic reviews with respect to the magnitude of benefit from screening, and among guidelines making recommendations about mammography. While some of the products of EBM (systematic reviews) might appear to conflict with some of the products of consensus conferences (guideline recommendations), the former recommending against mammography and the latter often recommending in favour of mammography, this appearance is illusory. The evidence, on its own, does not have the power to recommend. Conflicts arise among individuals and groups due to their differing interpretations of the evidence and divergent recommendations for which they use the evidence to argue.

Similarly, it might appear that generalized breast cancer screening guidelines conflict with the individualized practice of narrative medicine or EBM. However, even though guidelines make general recommendations on mammography for women in their forties, Solomon notes that the guidelines explicitly state that patients and their physicians should make an individualized decision. There is thus less conflict among the different methods than first meets the eye.

Rather than an untidy methodological pluralism, another way to describe the situation is as follows. Medical research has a dominant aim (‘translation’), and medical practice has a dominant epistemology (EBM). The aim of translation regulates the funding of research, and motivates the use of consensus conferences to disseminate knowledge. Meanwhile, EBM has been embraced by leading medical journals and medical training programs around the world. While medical consensus conferences and clinical guidelines predate EBM, they are now based on the principles of EBM and can be considered EBM tools (the use of evidence-based practice guidelines has been called the ‘using mode’ of EBM [3]). The practice of narrative medicine might sometimes conflict with the practice of EBM. But narrative medicine is a developing movement and approach to clinical medicine, not a dominant one. It does not yet have the political power of EBM. Thus, within research and medical practice, there is more hegemony and less egalitarianism than Solomon’s untidy pluralism perhaps suggests.

Making Medical Knowledge raises interesting questions about the function, theory and practice of medicine’s most influential movements. Modern medicine is a mess of many ‘medicines’, and while it is not the intention of this book to make this mess look tidy, Solomon does succeed in making it intelligible.

 

Acknowledgments

I gratefully acknowledge funding support from the Canadian Institutes of Health Research.

 

Funding

Canadian Institutes of Health Research.

References

  1. Solomon M. Making Medical Knowledge. Oxford: Oxford University Press, 2015.
  2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence Based Medicine: What It Is and What It Isn’t. British Medical Journal 1996;312:71 – 72.
  3. Straus S, Glasziou P, Richardson WS, Haynes B. Evidence-Based Medicine: How to Practice and Teach It. Edinburgh: Elsevier Churchill Livingstone, 2011.

The Reading Room: A review of ‘Medical Humanities & Medical Education: How the Medical Humanities can Shape Better Doctors’

14 Oct, 15 | by cquigley

 

 

Medical Humanities & Medical Education: How the Medical Humanities can Shape Better Doctors

by Alan Bleakley. Published by Routledge, 2015.

Reviewed by Dr Claire Elliott

How can medical education be changed to produce better, kinder medical students? How can they develop more astute clinical skills and improved awareness of the ethical and professional aspects of caring for and treating patients? In this book, Alan Bleakley argues for the democratisation of medical education – with integration of medical humanities as a core discipline – to help effect this change. He argues powerfully for a ‘critical medical humanities’ to be integrated into the medical curriculum in order to challenge the existing culture of medicine, which he feels breeds what he calls ‘insensibility’ and ‘insensitivity’.

Bleakley describes insensibility as the dullness to perception or blunting of close observation by clinicians. He feels that, for example, the decrease in physical observation and clinical examination in the consultation causes the loss of sensibility. He notes that there is a trend for medical students and doctors to request more investigations such as laboratory tests, x-rays and scans and subsequently their skills for ‘hands on’ examination of patients decrease. Indeed, the longer you are at medical school, the greater the lack of sensibility. He distinguishes this from insensitivity, which he describes as a way in which medicine (as currently taught and practiced) can lead to a lack of awareness or ability to be open to the experiences of peers and patients. Clinicians witness suffering all the time, but Bleakley notices that our current practice of medicine enables or encourages us not to see it.

Bleakley gives us a comprehensive view of the origins and growth of medical humanities in North America, UK and internationally. He observes that we have moved on from the exciting first wave of a new discipline to a more discerning and sophisticated second wave. He provides a full and detailed discussion of the choice of the name ‘medical humanities’, suggesting perhaps that it should be called ‘health humanities’. He argues for a critical medical humanities to reshape clinical thinking and practice to help students improve their tolerance of ambiguity. Bleakley argues persuasively that we need a new approach to medical education to help lessen the burnout, cynicism and high suicide rates that are prevalent amongst doctors. He believes that medical humanities helps stop medical students becoming inured to their patients and can help redistribute the power of noticing by experts to all of those involved in patient care. A key part of his argument is his suggestion that medical educators can challenge existing ways of teaching and practice by seeing the work of radical performance artists such as Bob Flanagan. Flanagan, who had cystic fibrosis, made a film, Sick: The Life and Death of Bob Flanagan, Supermasochist, in which he mixed his relationship with terminal illness and his sexual pleasure from being dominated by his partner.

The need for empathy in medicine is frequently encouraged, yet Bleakley discusses some of the problems with teaching it, as it can be superficial or even disingenuous. It may be that reading fiction can help with this. However, by taking us back to Homer’s Iliad, he (with Dr Robert Marshall who co-authored this section) explores how the powerful emotions of this epic story with its tales of war and killing, the heroic and the temporary nature of life on earth, can engage us emotionally in a more genuine way than teaching empathy through communication skills.

In focussing towards goals and making diagnoses, clinicians often do not see or hear what does not fit with their models of disease. In this way, we cannot see the individuality of the patient or where he or she does not fit in with our expected patterns. This tunnel vision approach is limiting for both doctors and patients. Bleakley suggests that creativity can be gleaned from learning to experience (in contrast to learning from, or through experience). This can allow the flourishing of imagination and new ways of experiencing medicine. Bleakley explores and describes a variety of types of creativity, including collaborations between jazz musicians and surgeons to matching volunteers with chronic illness in the community with second year medical students. Bleakley (who plays the saxophone) illustrates that improvisation and creativity, as used in playing jazz, can directly contrast with the reductive, pragmatic and minimalist approach to learning medicine.

Bleakley tells us about ways in which artists and doctors can work together to enhance observational skills. This can improve the noticing that is needed for clinical acumen and for sensitivity to patients’ needs. He emphasizes the need for awareness of all the senses to improve clinical acumen and decision-making. He describes examples of where clinicians are encouraged to observe, listen, smell, and touch (skills encouraged by William Osler), and this have been shown to improve their abilities. Bleakley also examines the role of close listening to the patients’ story in his exploration of narrative in medicine. He challenges the term ‘history taking’ and suggests that ‘receiving’ would be a better term as it suggests less of a power imbalance between patient and doctor. He explores the ways in which studying narrative can help clinicians, yet also suggests ways in which it can limit expression or cause harm.

Within the context of the medicalisation of normal life, Bleakley considers the ‘normality’ of taking prescription drugs. He investigates how the powerful (such as pharmaceutical companies) create an ‘insensibility’ in the general population of the potential dangers of taking medication for conditions that could be considered within the range of normal behaviour (such as ADHD, psychological problems). He cites a variety of novels where this medicine-taking activity is integral to the life of the characters.

Finally, Bleakley considers one of the common questions from within and outside medical humanities. He asks if the impact can or should be evaluated. He proposes that there are more important issues than measurement of impact: to be a critical contrast to the science based curriculum, to help clinicians be more humane and socially aware, to reconsider the meaning of wellbeing and health, and to educate for the tolerance of ambiguity.

This book is not an anti-doctor polemic, though it does challenge the existing structures and methods in medical education and clinical practice. By proposing a new and critical medical humanities, it suggests ways in which we can subvert the status quo and produce a more observant, imaginative, kinder and resilient medical student who works within an environment where the power is more equally distributed amongst the patients, and all of those who work within health care.

The Man in Bed Five by Jack Garnham

28 Jan, 15 | by BMJ

I go to see the man in bed five.

 

He winks at me. Cracked lips separate to reveal an imperfect set of yellow teeth as a wry smile spreads slowly across his face. It comes with an enormous effort. He looks worse; the burden of disease seems to weigh heavier with each passing hour. Sickness has slowly reshaped him, like an obsessive sculptor continually revising his creation. His wife fiddles nervously with her plain wedding band; I feel his decline, but for her each step in the inexorable march of his illness is devastation. She looks at me, and in her eyes I see a deep love and a profound fear. They have been married for forty years. He tells me about his two children. He loves them. His daughter lives in Australia. He has a dog that he takes for walks on the common. He waves a frail arm towards the trees outside the window and tells me that he is looking forward to going home. In our short time together he has granted me open access to his private world, to the countless unique experiences that conspire to create an individual. I will miss him when he is gone, the man in bed five.

 

This once vibrant character is dulled by his sterile surroundings: the bland hospital gown robs him of his humanity; the peeling walls and filthy windows drain him; plastic tubes run into and out of his body. For a moment the hospital is a colossal parasite, nourished by this wasted figure; it breathes in around me and exhales a fetid breath, content at having shelled the man in bed five.

 

I am protected. My fraying badge and cheap stethoscope defend me. The flimsy chart I hold is my shield. I am part of the profession, this most noble profession, and to hurt is weakness, to feel is fragility. He is his disease; he is a hospital number, a set of laboratory results, a trace on a machine, a faint bleep heard from the nursing station. To watch him break I must stand on the other side of the glass. I bid a clinical farewell to the peculiar collection of observations that was once the man in bed five.

 

One day the faint bleep fades. The rush of clinical medicine devours the mourning period; a different set of observations arrives to occupy the bed, and there are pressing results to chase and urgent investigations to order. He remains in my mind as the hours pass. Is it appropriate to grieve? Would it be easier to succumb to indifference? These were the questions asked of me by the man in bed five. Can you balance compassion with detachment? Can you manage the intolerable pain of regular loss? Can you walk the fine line? I bury these thoughts and continue to work.

 

As finals draw closer I find myself more frequently troubled by these questions.

 

I still have no answers.

 

Correspondence: Jack Garnham, Imperial College, London (jack.garnham09@imperial.ac.uk)

Physicians and Magicians: A Magical Education in Life, Death, Power, Potions and Defence Against the Dark Arts by Fiona Dogan and Mark Harper

20 Jan, 15 | by BMJ

Abstract

The worlds of magic and medicine both involve the sudden initiation of an intimate relationship between two complete strangers – the magician and their subject, or the doctor and their patient. Magic requires the subject to have some degree of trust in the magician, to accept that props and setting may be required to aid the illusion, and to witness such a high degree of skill that belief in the magician’s ability is sustained once the trick is complete. In the medical setting trust and confidentiality, the use of medical equipment, and the expertise and competence of the doctor are but a few essential components of a successful interaction. This is not to imply that the art of medicine is a trick, but rather a complex set of circumstances that can be engineered to promote the best possible outcome for both the doctor and the patient – or the magician and their audience.

The concepts of magic in the Harry Potter series can be used as examples to study issues that medicine raises in our own society. By focusing particularly on The Order of the Phoenix, The Half-Blood Prince and The Deathly Hallows, it is possible to compare the learning processes for both young magicians and medical students that are considered necessary to prepare them for life in their profession. Within the books there are interesting issues regarding perspectives of professional knowledge and power, with diverse examples of socio-economic status informing the treatment of certain groups by others. The psychology of the misuse of power by those in positions of authority and professionals acting under duress provide a measure of insight into the actions of doctors under a totalitarian regime. Finally the ethics of using science and magic are debated throughout the series, and provide valuable material for discussion of moral issues that can be translated directly to medicine.

Physicians and Magicians: A Magical Education for Physicians in Life, Death, Power, Potions and Defence Against the Dark Arts 

Education

There is a clear comparison between magic and medicine in the structure of training which can be classified into three, occasionally overlapping, areas which broadly equate to the classic educational paradigm of knowledge, skills and attitudes.

Right from the very beginning (we are excluding Owl Post although that may be equated to the acceptance letter) the similarities are striking. The young, aspirant magician’s trip to Diagon Alley, to buy a pile of books they don’t understand and a wand they don’t know how to use, equates to the medical student’s first visit to the University bookshop and purchase of stethoscope and other medical equipment. A cat, rat or owl would make a more interesting and interactive companion than a skeleton – if somewhat less relevant to medical studies. Here we see the first inklings of a professional attitude, in that both sets of students begin to take on the accoutrements that distinguish them from the non-medical or Muggle population.

There are also many similarities in the education process. Hogwarts requires seven years compulsory teaching, with the witches and wizards “coming of age” the year before they qualify. This provides a greater degree of freedom for them to practice their magic and hone their skills in the Muggle world, unprotected by the castle’s enchantments and restrictions on underage magic. Similarly doctors in the UK qualify after five years but have a further two years as junior doctors, gaining more responsibility during their sixth and seventh years.

Furthermore, both educations consist of a combination knowledge acquisition through book learning and skills through an apprenticeship. There is also a degree of crossover in the subjects studied: Potions and pharmacology, Arithmancy and chemistry, and Muggle Studies and communication skills.

There are even parallels in the same work hard, play hard ethic. Hours are long, learning goes on late into the night and copious quantities of beer are consumed – though there may be some suspicion that Butterbeer is not as potent as real ale.

Right from the beginning, both sets of students are externally regulated by either the General Medical Council (GMC) or the Ministry of Magic (MoM). As well as overseeing competencies these bodies define and regulate the appropriate attitudes through the ‘fitness to practice’ committee and, as Harry discovers more than once in the series, the Improper Use of Magic Department. Furthermore they effectively create a closed-shop which cannot be breached by the non-professional. (1,2)

However, whereas the GMC and the medical profession seem to be striving towards an ever more open and inclusive approach to the delivery of medicine, it could be argued that the MoM is rigidly sticking to a more archaic, paternalistic model. Muggles do not possess magic, and are generally not permitted to even know that wizards and witches exist. If mistakes are made and members of the Muggle population do become unintentionally aware of magic, it is acceptable to have memory charms performed on them without their knowledge or consent. This is demonstrated throughout the books, from the murders committed by Peter Pettigrew on the night of Voldemort’s destruction to the treatment of the Roberts’ family at the Quidditch World Cup in the Goblet of Fire. In The Deathly Hallows Hermione decides that the best course of action for her parents is to modify their memories, in order to make them forget they have a daughter and feel a sudden desire to leave the country. As she possesses the knowledge and skill to perform such a spell, she does this herself without consulting her parents or any of her fellow magicians. (3–5)

Much as one might, at times, wish to remove a patient’s memory of an interaction -ethics aside – conventional (i.e. non-magical) medicine still only has the power to induce prospective amnesia, and even then on an imperfect basis. (6) Additionally, research has shown that better outcomes are associated with patients understanding their illness and being involved in decisions about their treatment so maybe a shift towards a more informative and holistic partnership between patients, doctors, magicians and Muggles can only be a good thing. (7,8)

 

Power in life…

It’s not only actions that have consequences but attitudes too, particularly when it comes to wielding the kind of power possessed by physicians and magicians. The “use-or-not” of power is both a central theme of the Harry Potter books and an important consideration in terms of the doctor as magician.

The magical world is hidden from Muggles, as Hagrid explains to Harry at the very beginning of The Philosophers Stone, because people would want magical solutions to all their problems if they knew it was available. (9) His point is reinforced in The Half-Blood Prince during a conversation between the Muggle Prime Minister, the ex-Minister for Magic Cornelius Fudge and his replacement Rufus Scrimgeour:

‘The Prime Minister gazed hopelessly at the pair of them for a moment, then the words he had fought to suppress all evening burst from him at last.
“But for heaven’s sake — you’re wizards! You can do magic! Surely you can sort out — well — anything!”
Scrimgeour turned slowly on the spot and exchanged an incredulous look with Fudge, who really did manage a smile this time as he said kindly, “The trouble is, the other side can do magic too, Prime Minister.”’ (10)

This is useful in exploring the expectations some people – and some doctors – have about the power of medicine. In the past the physician was more like the magician, albeit one who used sleight of hand rather than real magic, creating power through obfuscation in a veneer of classicised language and instruments, such as the stethoscope, that put space between them and the patient. Interestingly, as their real powers have grown, the façade has come down to a large extent and patients can have much greater knowledge of their conditions and of the ‘spells’ possessed by the doctor.

Nonetheless, expectations have simultaneously risen and it often seems that patients think doctors should be able to do magic. Maybe it would help to show them how “the other side” also has “magic”; whether it is the ability of the virus to mutate to escape drugs and detection, or the cancer to hide in the patient’s own cells (DNA even) to evade chemotherapeutic spells and radiation wands, only to re-emerge like Voldemort from his Horcruxes. There is still no “Magic Bullet” to specifically target every disease process. (11–14)

The exchange above also illustrates how the patient can be affected by the amount of power they feel they have over their condition. As he feels he is losing control of the situation, the Muggle Prime Minister cannot contain himself any longer, and his words are redolent of patients and their relatives in the face of a poor prognosis. (15)

The Dursleys are Harry’s Muggle family from his mother’s side. Despite being among the few Muggles who know about magic, they choose to ignore it for as long as is possible because they see magicians as troublemakers and a source of embarrassment. They pretend that Harry is mentally unstable rather than admit to him being a wizard. It is only in The Order Of The Phoenix when…

“The arrival of Dementors in Little Whinging seemed to have breached the great, invisible wall that divided the relentlessly non-magical world of Privet Drive and the world beyond.”

…they see the possible impact of magic on their own lives, and they begin to ask for Harry’s advice and guidance.

There are patients who have an analogous distrust of doctors, to the extent that they will leave conditions far longer than they should in order to avoid confronting the medical world. The Dursleys represent this group and demonstrate how people can have deep-seated and rationalised (though not necessarily rational) views. The Dursleys are, therefore, useful characters to consider when dealing with patients can be very afraid of a condition that they do not fully understand. (2)

 

… and power over death

The biggest ethical dilemma raised in Harry Potter books relates to the death of Albus Dumbledore in The Half-Blood Prince. After putting on a cursed ring by mistake Dumbledore asks Severus Snape for help. Snape uses a potion to trap the curse in Dumbledore’s right arm temporarily, although they both know he will still be dead within the year. Dumbledore then asks Snape to kill him when the time comes, as this will prevent him suffering for longer than necessary whilst also solidifying Snape’s position with Lord Voldemort in his double agent role.

This situation is analogous to palliative treatment and physician-assisted death. As Snape delivers the final blow himself rather than provide the means for Dumbledore to take his own life, and Dumbledore is conscious up until the Avada Kedavra killing curse hits him, it would most likely fall under the category of voluntary active euthanasia. (5,10)

The first issue this series of events raises is that of the ethical dilemma that surrounds the boundary between a duty of care and actively shortening a patient’s life. Snape finally agrees to undertake this task ‘for the greater good’- to protect his double agent identity and therefore help assure the safety of the students at Hogwarts.

In medicine the death of a terminally ill person in order to benefit the life of another is one of the core issues when discussing the legalisation of euthanasia. Setting aside the moral issues, benefit may be derived from both the individual, in terms of reduced suffering, and the collective, through the reduced drain of limited resources. However, this must be set against the need to protect elderly and vulnerable people, and provide optimum medical care. (16)

The second issue this event raises is the emotional effect on the doctor or magician who delivers the final, fatal blow. We see Snape hesitate before killing Dumbledore and, even though at this stage he is portrayed as Voldemort’s henchman, we can feel his reluctance. This is despite the fact that he is acting on a well thought-out and considered advance directive. As Dumbledore explains in The Deathly Hallows:

“I ask this one, great favour of you, Severus, because death is coming for me… I confess I should prefer it to be a quick, painless exit to the protracted and messy affair it will be…”

Nonetheless, Snape fears for the consequences to himself:

‘“That boy’s soul is not yet so damaged,” said Dumbledore. “I would not have it ripped apart on my account.”

“And my soul, Dumbledore? Mine?”

“You alone know whether it will harm your soul to help an old man avoid pain and humiliation,” said Dumbledore.’ (5)

This illustrates a common argument against euthanasia, regarding the psychological burden that could be felt by the enabling physician. This has been a subject of specialist research for many years, involving doctors who work in clinics such as Dignitas in Switzerland and those who are required to administer lethal injections to criminals in the United States. (17)

Part of the problem is that Snape is, necessarily, acting alone. It would be much easier if he had advice, support and objectivity from others. It therefore underlines the need in medicine for a multidisciplinary approach to these situations. (18)

The description of the last moments before Snape kills Dumbledore bring up two further issues. The first is the effect on the peripheral characters: in the medical context, the relatives; in this context, Harry, who is shocked and frightened by the unfolding events.

‘“Severus…”

The sound frightened Harry beyond anything he had experienced all evening. For the first time, Dumbledore was pleading.’

It is not until The Deathly Hallows that it becomes apparent Snape was acting on Dumbledore’s wishes. At this point it seems that the old wizard is begging for his life to be spared.

‘…Snape gazed for a moment at Dumbledore, and there was revulsion and hatred etched in the harsh lines of his face.

“Severus… please…”

Snape raised his wand and pointed it directly at Dumbledore.

“Avada Kedavra!”’

But furthermore, it is impossible to tell whether Dumbledore had actually changed his mind at the last minute and was, as it seemed to Harry, pleading for his life. And this is something that needs to be considered with medical euthanasia, particularly in patients with degenerative diseases that may compromise their ability to communicate or comprehend over time. These decisions are often made a long way in advance, and it can sometimes prove very difficult to be sure that their wishes have not changed. (10,19)

 

Defence against the Dark Arts

The steady implementation of the totalitarian state in the second half of the Harry Potter series closely mirrors the rise of Nazism in Germany prior to the Second World War. The persecution of the Jews and the Muggle-borns, Neville Chamberlain’s appeasement policy and Cornelius Fudge’s feverish denial, and the use of propaganda by Voldemort and the Death Eaters are but a few similarities. The actions performed by different magicians under this regime is an interesting study in psychological terms, and provides some insight into the behaviour of professionals such as doctors during wartime and under duress. (20)

Under the rule of Hitler it was deemed necessary for doctors to experiment on classes of people who were considered ‘lesser beings,’ in order to further knowledge and discoveries in the field of medicine. This began with the psychological dehumanisation of the Jews and other ‘undesirables’ through smear campaigns, blaming them for the defeat of Germany in 1918 and the subsequent economic depression. Through the use of careful and steady propaganda it seemed like an almost natural progression for the Jews to eventually be segregated and placed on a registry system. Some doctors chose to accept the idea of the “Jewish plague” and took pride in providing what they believed to be a valuable service to Germany and scientific advancement, whilst other doctors performed their duties under duress to avoid being killed themselves. It became commonplace for those within the medical profession to control, torture and kill Jews, homosexuals, the disabled and many others as part of their day’s work, and to record the results of the various experiments performed. (21)

In Harry’s world there are certain witches and wizards who can be used to represent the actions of different medical professionals under the oppressive regime in Nazi Germany. Firstly interesting parallels can be drawn between Hitler’s “Angel of Death” Dr. Josef Mengele, and the Head of the Muggle-Born Registration Committee Dolores Umbridge. Mengele had a background in genetics and twin studies in particular, and revelled in the fact that Hitler’s regime allowed him to further his studies through experimentation in a way that would not have been possible previously. Similarly Umbridge is vociferous regarding the offensive nature of half-breeds and later Muggle-borns, and seems unperturbed who is in charge as long as she is able to increase her power and her freedom to use it. It later comes to light that she abused her position or power as early as the beginning of The Order of the Phoenix, when she illegally sent Dementors after Harry to try and silence him regarding Lord Voldemort’s return. She was initially appointed by the Ministry as the Defence Against the Dark Arts teacher at Hogwarts in order to keep a closer eye on Harry and Dumbledore, but rapidly progressed up the ranks due to her dedication and ruthless personality. Whilst not in league with Voldemort himself, she certainly upheld his ideals and, similar to Mengele in Germany, seemed to delight in using the political situation to her advantage to achieve her aims. (2,21)

Alecto and Amycus Carrow represent the Nazi doctors who truly believed in their leader’s vision and would do everything in their power to assist in its’ realisation. They differ slightly from the type of doctor portrayed by Umbridge, as they believed in Voldemort’s particular ideals rather than his general approach. The Carrows excelled under Voldemort’s rule during the Second Wizarding War, and revelled at the chance to freely use the previously illegal Unforgiveable Curses: Imperio (control), Cruciatus (torture) and Avada Kedavra (death) – the same methods used on the “undesirables” by the Nazis during the Second World War. Harry is depicted on posters and referred to by the Ministry as ‘Undesirable No.1’.

Professor Snape’s true loyalties are in question up until his dying moments at the end of The Deathly Hallows, where it is revealed that he had indeed been trying to protect Harry all along. Working as a double agent for Dumbledore, he made the difficult decision to continue to work for Voldemort in the hope that he could exert some control over the Carrows’ punishments inflicted upon the students they were in charge of. This has previously been the case with doctors who speak out after working under duress, in an attempt to limit suffering as much as they can in a difficult situation. (5)

The character of Voldemort himself raises important issues regarding the psychology of a dictator. Voldemort used great acts of evil to split his soul into 7 pieces (Horcruxes) to attempt to gain immortality and power. The concept of ‘doubling’ describes how a person is able to commit acts previously abhorrent to them, as they simply ‘switch off’ their other side. This has been offered as an explanation why people, such as Nazi doctors, were able to torture and kill ‘undesirables’ on a regular basis. (10,21)

Conclusion

Throughout the Harry Potter books there are many comparisons that can be drawn between the magical and the medical world. The similarities and differences that have been highlighted give us an original way of looking into important issues concerning the medical profession, and the magician-Muggle relationship raises interesting points regarding the doctor-patient interaction. Ultimately it leaves one wondering whether we as physicians try too hard to be magicians? Or is it that patients actually want us to be magicians? As always, the reality probably lies somewhere between the two extremes.

 

References

  1. General Medical Council L. Tomorrow’s doctors: Recommendations on undergraduate medical education. 2009.
  2. Rowling J. Harry Potter and the Order of the Phoenix. 1st ed. Bloomsbury; 2003.
  3. Rowling J. Harry Potter and the Prisoner of Azkaban. 1st ed. Bloomsbury; 1999.
  4. Rowling J. Harry Potter and the Goblet of Fire. 1st ed. Bloomsbury; 2000.
  5. Rowling J. Harry Potter and the Deathly Hallows. 1st ed. Bloomsbury; 2007.
  6. Twersky RS, Hartung J, Berger BJ, McClain J, Beaton C. Midazolam enhances anterograde but not retrograde amnesia in pediatric patients. Anesthesiology. 1993 Jan;78(1):51–5.
  7. Coulter A. Paternalism or partnership? BMJ. 1999 Sep 18;319(7212):719–20.
  8. Bond C, Blenkinsopp A, Raynor DK. Prescribing and partnership with patients. Br J Clin Pharmacol. 2012;74(4):581–8.
  9. Rowling J. Harry Potter and the Philosopher’s Stone. 1st ed. Bloomsbury; 1997.
  10. Rowling J. Harry Potter and the Half-Blood Prince. 1st ed. Bloomsbury; 2005.
  11. Williams S, Weinman J, Dale J, Newman S. Patient expectations: What do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract. 1995 Jan 6;12(2):193–201.
  12. Kenten C, Bowling A, Lambert N, Howe A, Rowe G. A study of patient expectations in a Norfolk general practice. Health Expect. 2010;13(3):273–84.
  13. Illich I. Limits to Medicine: Medical Nemesis – The Expropriation of Health. Marian Boyars; 1976.
  14. Strebhardt K, Ullrich A. Paul Ehrlich’s magic bullet concept: 100 years of progress. Nat Rev Cancer. 2008 Jun;8(6):473–80.
  15. Lupton D. Medicine as Culture: Illness, Disease and the Body. SAGE; 2012. 79-136 p.
  16. Harris D, Richard B, Khanna P. Assisted dying: the ongoing debate. Postgrad Med J. 2006 Aug;82(970):479–82.
  17. Stevens KR Jr. Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians. Issues Law Med. 2006;21(3):187–200.
  18. Seale C. Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes. Palliat Med. 2009 Jan 4;23(3):205–12.
  19. Hotopf M, Lee W, Price A. Assisted suicide: why psychiatrists should engage in the debate. Br J Psychiatry. 2011 Jan 2;198(2):83–4.
  20. Curthoys A. Harry Potter and historical consciousness: Reflections on history and fiction. Hist Aust. 2011 Apr 13;8(1):7–22.
  21. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books; 2000.

Author contact details:

1. Fiona N Dogan, 5th year BM BS student, Brighton and Sussex Medical School

f.dogan1@uni.bsms.ac.uk

2. Dr C Mark Harper BSc MBBS FRCA, Consultant Anaesthetist, Brighton and Sussex University Hospitals
mark.harper@doctors.org.uk

Deborah Bowman in conversation with Leslie Jamison, author of ‘The Empathy Exams’

22 Jun, 14 | by Deborah Bowman

 

 

Join the Editor of Medical Humanities, Deborah Bowman, in conversation with Leslie Jamison as they discuss her acclaimed essay collection ‘The Empathy Exams’ and more. Leslie’s work questions how we understand each other and the concept of empathy, drawing on her time as an actor working with medical students and her own experiences of illness and vulnerability. It promises to be a fascinating evening and a rare opportunity to meet an author described by the New York Times as ‘extraordinary’.

This is a free public event, open to all and part of the St George’s, University of London series The Art of Medicine.

Details:

Date: Monday 7th July at 5.30 p.m.

Venue: Boardroom H2.5 Hunter Wing
St George’s, University of London Cranmer Terrace,
London SW17 0RE

Register via e-mail: events@sgul.ac.uk

Hope to see you there.

 

Ayesha Ahmad: Review of ‘Able-Bodied – Scenes from a curious life’ by Professor Leslie Swartz

26 Feb, 13 | by Ayesha Ahmad

 

Having had the privilege to meet with Professor Swartz, I read his most recent book publication, ‘Able-Bodied – Scenes from a curious life’ with the jovial sounds of his uncanny ability to reflect on human nature and experiences in the background.

 

I certainly found Professor Swartz’ presence evident in the somewhat apologetic way he introduces and describes his family, as if telling a story and telling a secret amount to a similar thing. Yet, his words behold a compassion and gentleness that even the greatest of sentiments often fail to display.

 

more…

Ayesha Ahmad: Call For Abstracts – Second Annual Western Michigan University Medical Humanities Conference

26 Mar, 12 | by Ayesha Ahmad

Second Annual Western Michigan University Medical Humanities Conference

September 27-28, 2012; Kalamazoo, Michigan

Proposals should be submitted electronically by July 15—in either .doc/.docx or .pdf format—to
medical-humanities@wmich.edu

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James Poskett: Material and visual culture of conferences

9 Dec, 11 | by James Poskett

Conferences can be somewhat dry affairs. Papers delivered as long droning monologues are liable to send even the most hardened academics into a dreary stupor. The more enticing discussions can also take their toll as the days wear on, debate often returning to ancient disputes. So what better way to break up the day and keep everyone fresh than with an outing to the cinema?

At the recent Communicating Reproduction conference we were all sent to see Helga (1967). Of course, this outing wasn’t frivolous but rather an opportunity for us to engage with the substance of the conference: the history of reproduction through communication including text, images, film and sound.

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Ayesha Ahmad: Review of ‘Doing Clinical Ethics’ by Dr Daniel Sokol

4 Dec, 11 | by Ayesha Ahmad

Since Hippocrates in early 5 B.C., Medicine has carried an ‘angel on its shoulder’; a reflexive gaze on the skill, and phenomenologies of healing between the doctor and his patient. Ethics is a code, a practice, and a guide amid the terrain of the hands that tend to the body using instruments of medicine’s enterprise. Referring to the Oath:

I will preserve the purity of my life and my arts’.

Daniel Sokol, Honorary Senior Lecturer at Imperial College, London and recently qualified barrister, undertook the challenge of fitting ‘ethics’ into our contemporary medical practice; whereby Medicine is confronted by a body unprecedented in relation to the ways in which we can perceive, examine, intervene, create, and prolong the existence of our bodies; our lives.

more…

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