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Poetics

“Congenital Glaucoma”: Commentary

12 Jul, 17 | by amcfarlane

Dr Richard Ratzan gives us a commentary on his poem “Congenital Glaucoma, published in BMJ Medical Humanities, and explains why he decided to write about this case using the sonnet form.

This little girl – she was probably about 13 or 14; I don’t remember since it was about 10 years ago – was from Mexico, almost certainly illegally but I do not remember that for certain either. She was with 2 or 3 boys her same age. What struck me about the case – and prompted me to write about it – were the following: first, how animatedly happy they all were. In retrospect, given how devastated I was that she was not only blind but preventably so, I was impressed that this misfortune was not precluding their youthful joy. (Whether she was so joyful when the ophthalmologist gave her the official bad news in his office – as he did since I called him about her two days later – I do not know.) Secondly, as someone who makes it a practice to look in at least 3 to 4 sets of fundi a shift – I find it useful and I do not want to lose this skill, as I would were I to use it, as my residents do, only when I “need to”, e.g., for severe headaches or visual problems – I was astounded, as I have not been that many times in my professional life, by the sight of her fundi: each cup was a bottomless pit of featureless whiteness, with vessels falling off into them from the edge of her retina as though falling off the edge of the universe. (I was also acutely aware then, as I write “sight” now in the preceding sentence, of the irony that it was only my good vision that could diagnose her lack of it.) Thirdly, I was struck by how blasé about it my resident, a good PGY3, was. Yet again I marveled at young physicians’ lack of ability to marvel. Is it their lack of experience, the paucity of fundoscopic examinations (not that they do that many these days or ever will accrue a database with which to compare) against which to measure medical horror when they see it? Or is it simply a different attitude they bring to work, an unwillingness or youthful inability to see the wonder of clinical medicine when it rears up in front of you? It is not callousness, at least in this young resident’s case. And fourthly and lastly, I grieved at the tragedy of her being born in Mexico without the resources we in the U.S. take for granted. If her parents here had noticed her trouble seeing as a younger girl – as I am sure hers in Mexico had – she would have gone to an ophthalmologist and – case closed – gotten preventive therapy. No blindness. Which is why, as someone who knew little girls like this when I used to spend a lot of time in Mexico, I referred to it as a sacrifice – a sacrifice of Mexico’s poverty and inadequate health care. A sacrifice I tried to make more historical and poetic with references to pre-Columbian mythology.

Why a poem, and why and how a sonnet? I have been interested in telling medical stories, vignettes, case histories, in verse for years since there is an economy to verse and a freedom “to tell all the truth, but tell it slant” [ref 1], a quotation (the title of the poem, actually) from Emily Dickinson that my late physician-poet friend, John Stone – and a far greater poet than I – liked to invoke whenever he was asked the same question – why poetry? But why a sonnet and not a villanelle [ref 2] or a sestina [ref 3]? It is the liberating mode of poetry and the simultaneous discipline, the challenge, of packing everything into a tightly defined package of a sonnet’s 14 lines. First I must squeeze the facts of the case into the octet, the first 8 lines, and then the exposition of the ideas, which exposition will only work if I have been successful in the first 8 lines, into the terminal sestet, the final 6 lines. Although Shakespeare usually uses the last two lines as the “volta” (Italian for “turn”, the axis point at which the poet gets to the crux of the poem) of the sonnet, I almost always follow the Petrarchan model using a sestet to “wrap up” the case. What I find most challenging is the tension between being too economical – writing solipsistically cryptic references only I understand – and prosaically literal. The former borders on the opaque (Wallace Stevens can pull it off; I can not). The latter is the case history we have all learned to use when dealing with other medical listeners. In between is poetry. As my second son said with amazement some years ago, upon hearing that I had attended a standing-room-only poetry reading by Mary Oliver at Smith College, wondering what the big deal was about poetry, “Poetry is incomplete prose. There are words missing.” (I didn’t have the heart to tell him that his definition of poetry was a veritable haiku. I did not want to ruin his day.)

References

1. Dickinson, Emily. “Tell all the truth but tell it slant”. Poetry Foundation. Accessed May 5, 2017.
2. Williams CK. “Villanelle of the Suicide’s Mother”. Reviewed by Ratzan RM. Accessed May 5, 2017.
3. Hadas, PW. “To Make a Dragon Move: From the Diary of an Anorexic. Reviewed by Donley C. Accessed May 5, 2017.

Reclaiming Reflection: Creative Writing and the Medical Humanities (3)

16 Sep, 16 | by cquigley

 

 

Reminiscence Bumps: self-mythology and the landscapes of the mind

by Eleanor Holmes

 

When I think about the landscapes of the mind, I recall the undulations of the brain’s surface. The ridges and valleys of cortex, the gyri and sulci I had learnt about in my neuroanatomy classes aged nineteen. Those white plastic tubs we eased open to reveal two, pale grey hemispheres floating in straw-coloured formaldehyde. That clinical but distinctly organic smell of burnt rubber, astringency and wax. How we sliced sections of brain with something that resembled the knife my father used on home-cured ham. How surprisingly soft it was to cut.

Prior to starting my Spring School creative writing week at Newcastle University in 2014, I had read Pieces of Light: The New Science of Memory by Charles Fernyhough. It has been an invaluable source of information on the latest scientific research on memory, particularly autobiographical memory, but it has also been hugely inspirational as a piece of science writing (or creative non-fiction). Two things particularly stood out to me when reading the book and in researching this subject. Firstly, the notion that memory is random and secondly, that it is ultimately self-serving. As Charles Fernyhough states and the American writer and physicist Austin O’Malley wrote:

“Memory is a crazy woman that hoards coloured rags and throws away food.”

The randomness of memory is something that has often struck me. Why do we remember odd, apparently insignificant facts and not the things that would seem more important when looking back on our lives? Why can I recall the sandwich filling (garlic sausage) my brother threw out of the window that blocked the guttering, aged thirteen, but cannot remember the name of the actor who lodged with us? How can I remember the cigarette brand and packaging my grandmother smoked (Benson and Hedges, Silver) and a conversation we had about a TV programme aged fourteen but cannot remember any of the details of her funeral?

 Yet it is the small details, those seemingly random colourful rags that stick and then float to the surface when we recall the past, especially it seems when writing about it. It is particularly that rich period for memory from our teens to our twenties, the reminiscence bump that Charles Fernyhough writes about in Pieces of Light, that keeps emerging in my writing, whether I want it to or not.

“A British study showed that when autobiographical memories were cued verbally, there was a predictable peak between the ages of eleven and twenty-five: the well replicated phenomenon known as the reminiscence bump.”

The majority of the poems I wrote in 2014 for the Spring School fell into this verbally cued reminiscence bump. On the first day of our course, the poet Bill Herbert asked us to think about “where am I from?”, followed by “where do I identify as home?” This led to an exploration of self and belonging that I initially found hard to write about. I was born in Bristol, we moved to the Midlands when I was seven and there I stayed until I left for Nottingham University.

I disliked living in land-locked Warwickshire and didn’t manage to change this land-bound situation when I moved to Nottingham for university, but at least I had moved north. I have always been moving north, by increments, as well as edging closer to the sea. I had wanted to go to medical school in Newcastle but didn’t get an interview. I wonder whether it is really a coincidence of fate that led me to the North East (Durham initially and then Newcastle) or something that needed to happen; a kind of embodied genetic pull to this landscape next to the sea. Tynemouth is where I live now, positioned on the mouth of the Tyne and next to the North Sea with its wild surf and beaches, stretching up the Northumberland coast to Scotland like a golden thread. This is the place I am now most likely to call home.

What emerged from Bill Herbert’s class was a need to write about my birth, my mother and our at times difficult relationship. It was a theme that was to flow through all my submitted poems, along with water as the element that I most identify with. Bill also encouraged us to think of body as place, by reading an extract from Paterson by William Carlos Williams, a theme that resonated with me and the obsession I have with writing about the human body and my memories of anatomy and dissection from medical school.

It is now clear to me (after six years of pursuing a writing life alongside medicine) that when I write I don’t always decide in advance on form, I just like to write. It is later that I make a decision as to whether I am writing poetry, prose or script, when looking back over the words. Fiona Evans took our scriptwriting class mid-week and I was encouraged when she advised us not to be tied to form or structure. Her session also introduced me to Marina Carr as a playwright, specifically her play By The Bog Of Cats. As we read sections of this script it felt to me to be very poetic and suddenly the idea of scriptwriting seemed less daunting.

Learning about performance and the concept of the clown with ‘Miscreations Theatre’, and the history behind the art form with Helen Limon as facilitator, also influenced my poems, particularly the idea of embracing the ridiculous. The importance of being able to laugh at yourself I hope comes through in my writing. Black humour, said to be a medical trait but more often than not a coping strategy for the difficulties encounters of healthcare work, is something I often explore when writing about medicine and health. Too easily my writing can stray towards the subject of death; my father jokes that it is my favourite topic. It is perhaps an occupational hazard but I hope to strike a balance between being respectful of serious subjects whilst seeking out the humour inherent in most human interactions.

In William Fiennes’s class we were asked to draw a map from memory. I ended up drawing a detailed plan of my childhood home where we lived from the age of seven to sixteen, and wrote about the memories attached to this house. Here it seemed was an endlessly rich seam of childhood and teenage memories in terms of a reminiscence bump that still feels very vivid to me. I liked the idea of writing about my territory being invaded and many stories bubbled up from this exercise. I hoped it would link several themes together by highlighting an aspect of my growing up and the emergence of identity. This aspect of identity as an internalised life-story is another recurring theme in my writing, one that is so clearly linked to reminiscence bumps and the reason psychologists believe this age looms so large in people’s memories.

I am aware that much of what I’ve learned in creative writing workshops is that these small details – proper nouns, the use of all five of the senses when we write – that help to bring our writing alive. This must be linked to the way we remember. When we write we are creating a world (the world) for the reader, just as we do for ourselves when we remember the past. Memories are not stored like files in a cabinet, they are created anew each time we recall the past. We narrate our lives as serves us best at the time of recollection.

Childhood memories particularly are often recalled through collaborative acts of remembering, like a collage. I know that in a number of the poems I have written some details I’ve had to ask my mother about, as I couldn’t recall something exactly, or the name of a place or person. My mother, father and brother have helped me fill in the gaps where needed, but it is also noticeable that they do not remember everything as I do. Charles Fernyhough writes:

“The idea that the past is a story that we tell ourselves, whose vividness can be no guarantee of its authenticity, highlights our reliance on language for social acts of remembering. If our autobiographical memory system serves to create a coherent narrative of our own past, it is a system that can frequently fool us into believing stories that are not true, as evidenced by the fact that many of us ‘remember’ events that we no longer believe actually happened.”

This was the concept that I was fascinated to read about in Judith Schalansky’s beautifully realised Atlas of Remote Islands: Fifty Islands I have not visited and never will. Christy Ducker recommended this book (it’s really very beautiful, brilliant and unique) and the preface particularly intrigued me:

“The absurdity of reality is lost on the large land masses, but here on the islands, it is writ large. An island offers a stage: everything that happens on it is practically forced to turn into a story, into a chamber piece in the middle of nowhere, into the stuff of literature. What is unique about these tales is that fact and fiction can no longer be separated: fact is fictionalised and fiction is turned into fact.”

I think everything I write tends to start out as an exploration of autobiographical memory that I then run with, to a greater or lesser degree. Christy Ducker invited us to think of a place that we were experts on, then asked us to put someone into that environment who had no knowledge of it. This was the inspiration for My Mother Visits the Dissection Room, a blend of factual information in terms of place (the dissection room I remember from medical school and that I have lately re-visited) and my knowledge of my maternal relationship that ended up as a poem about an imagined scenario that incorporated all of these elements.

 

My Mother Visits the Dissection Room

by Eliot North

 

She said she wanted to go there.

So I pulled some strings,

read her the rules.

“Sensible shoes?” she said.

“Yes Mother. Plus clothes

you don’t mind ruined.

Fixers, they don’t wash out.

The smell will get you,

but not of death. More chemicals

like wax and rubber.”

But my mother, being my mother

didn’t seem to mind.

Walked right up to the

plastic head,

stuck her hand inside.

“You won’t even know

I’m here,” she said.

Pulled on a dark-blue lab coat.

Watched closely

as I unzipped the body bag,

revealed cavities and cages.

Stood on tiptoes to peer inside,

scribbled in her notebook.

So I placed a stool

three feet away;

her territory and mine.

When the students filed in

they looked at her,

the older woman with colourful shoes.

Whilst I quizzed the students,

she daubed her paints.

At the end they crowded round her.

Admired her line and

brave use of colour

whilst I put the organs back.

As the students left

she called out to them.

“Call me Poppy!” she cried.

They waved from the door.

“Weren’t they interesting?

What a wonderful body,

all those nooks and crannies.”

I slung the heart in a plastic bag.

Looked at my watch

before herding her out.

Then as we went to the door

she turned round and said,

“Shall we say the same time next week?”

 

Published by Ink, Sweat and Tears on 30/08/2016 http://www.inksweatandtears.co.uk/pages/?p=11697

 

These two concepts, the unreliability of memory and the way in which we narrate our lives using a blend of fact and fiction to best suit ourselves at the time of telling, is endlessly fascinating to me. I’ve struggled at times to differentiate between what I think actually happened and what I have imagined when recalling the past. The poems I write are often a conscious blending of fact and fiction, something termed in memory research as imagination inflation (what a great term!) I don’t like to pin down my writing necessarily as creative non-fiction. I would prefer to think of my poems as fictionalised truths. In this my drive towards a cohesive narrative wins each time; I will bend the facts to meet the needs of the story I am writing. Who hasn’t done that after all?

 

Acknowledgments

This essay draws on the poetry, prose and script suggested by tutors Bill Herbert, Christy Ducker, Fiona Evans, Helen Limon and William Fiennes, as well as the following books, performances and readings:

Fernyhough, Charles, 2013, Pieces of Light: The New Science of Memory, London: Profile Books Ltd. (quoted passages p 3, p 20, p 54.)

Ishiguro, Kazuo, 1995, The Unconsoled, London: Faber and Faber Ltd.

Lively, Penelope, 2013, Ammonites and Leaping Fish: A Life in Time, London: Penguin Books Ltd. Extract read by the author at NCLA Reading: ‘Penelope Lively in conversation with William Fiennes,’ on 1/5/14.

Payne, Nick, 2014, Incognito, London: Faber and Faber Ltd. (Script) and Performance at Live Theatre, Newcastle, 30/4/1/4 followed by post-show discussion with the author, neuroscientists and clinicians working with memory disorders.

Schalansky, Judith, 2010, Atlas of Remote Islands: Fifty Islands I have not visited and never will, London: Penguin Books Ltd. (quoted passage pp. 19 – 20)

Henig, Robin Marantz, The Reminiscence Bump: People looking back on life remember their twenties best. Psychology Today, Posted October 24, 2012. Cited https://www.psychologytoday.com/blog/cusp/201210/the-reminiscence-bump 2/8/16

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

Poetry Book Review: The Wound Dresser

7 Sep, 16 | by cquigley

Two poetry book reviews will be featured this week. The second review will appear on Friday.

 

WoundDresser

 

Jack Coulehan, The Wound Dresser (Albuquerque: JB Stillwater, 2016)

Finalist for the 2016 Dorset Poetry Prize, selected by Robert Pinsky (Poet Laureate of the United States from 1997 to 2000).

Reviewed by Barbara Salas

 

The Wound Dresser by Jack Coulehan is a collection of 77 poems that explore the reality of being a physician, reflect on health and illness, and delve into the experience of suffering from different angles. In the following lines I will share how Coulehan’s poetry has made me reflect on diverse aspects of life, disease and on the art of medicine.

The book is the author’s sixth collection of poems, and its title alludes to a composition by Walt Whitman (whose photo appears on the book’s cover): verses that speak about the care of wounded soldiers during the Civil War, and to which Coulehan dedicates his very first piece of the collection. This theme of looking after the sick is central to the author’s poetry.

The order of the poems, though not clearly stated, seems to reveal the passage of time: from the “The Secret of the Care”, which opens the first section exploring the feelings of a junior doctor, to the very last poem of the series, “Retrospective”, which is a reflection on forty years of medical practice. This subtle timeline is structured into four parts, each one orbiting around common themes.

The first section comprises poems that generally reflect on the doctor-patient relationship. A recurrent element of these compositions is the idea of the physician as the one who witnesses the inner secrets of the patient. In “Take Off Your Clothes” we are invited to think about the physical examination: the patient exposed and vulnerable, and the doctor as the one with access to the “narrative in [the patient’s] flesh” (p. 23). Physician and patient are “intimate companions” in a journey through the intricacies of the body, in which we appreciate compassion and loving care from the doctor, but also patent fear from the patient: a topic often conveyed in Coulehan’s poetry (e.g. “The Rule of Thirds”, pp. 26-7).

However, the relationship established between doctor and patient, though close, appears to be at the same time “detached”, perhaps because the access to those secrets does not necessary grant intimacy. In fact, it sometimes seems to signify the opposite, something like a “cold distance”. The four poems “A Lesson in Diagnosis” (pp.5-8) convey to me this tension between “union” and “separation”. The closeness is transmitted through the acknowledgement of the patient’s vulnerability during the clinical exam (“During the discussion/ she keeps trying without success/ to cover her nakedness with a sheet.” p. 7), but the distance is present in the detachment that the doctors demonstrate both in their use of language as well as in their actions (“He drags us to another case —/ this one, a supraclavicular mass./ No one stoops to pick up her glasses.” p. 6). It is clear that while the patient is embedded in pain and anguish, the doctor sees and identifies the problem from afar, without being part of it or experiencing it.

Some poems reflect on the process of learning to practice medicine, and the feelings and thoughts that the clinical encounter trigger in the physician. The need to pretend to be competent (“I palpated/ their abdomens, balloted their livers,/ and listened to respiratory crackles,/ while disguising the depth of my doubt/ with a kindly, but serious look.” p. 3), or the difficulty in interacting with some patients (“I was surprised to find/ how much I disliked some of the patients” p. 3) is present in “The Secret of the Care”, the first poem of the collection. This made me ponder on the physician as the one who has two identities that sometimes stand in tension: on the one hand, the “professional” side that actively cares for the patient; and on the other, his inner world full of thoughts, worries and prejudices that are often hidden in the consultation yet present in his mind.

Finally, the contrast between the patient’s inner life and the painful reality of being ill captured my attention in this section. “The Silk Robe” (pp. 16-7), offers a glimpse of the patient’s life beyond the clinical setting by underlying details like her “blue silk robe”, her “scent” or her “delicate gold chain”. What those details evoke sharply contrast with the reality of her medical condition: the “cultures”, the “catheter”, and the “bed rest” reminds us that she is sick. While reading this poem I thought about the clinical encounter, during which sometimes doctors interact with patients as if their whole being were only their disease. Those doctors sadly forget that the patient is first and foremost an individual; a human being with an inner life that has to be acknowledged and respected. These two dimensions (the person as patient and as individual) are beautifully captured in Coulehan’s literary work.

The second section conveys, through reflections on historical figures or events and mythical accounts, how medicine has changed through time. It also reflects on how human elements like prejudices, fears or beliefs can shape the interaction between doctors and patients, both in the past and today. “To the Heart of Lazar Riverius, Galenist Physician” (p. 40) presents the contrast between the current medical practice (one that operates without “faith” and in a somewhat “mechanical” fashion) and the medicine of the past, which used to embrace the spiritual dimension of the person more openly (“Today the surgeons shut you down,/ open, patch you, put in plastic —/ and not a single Sign of the Cross!”).

In “McGonigle’s Foot” (pp. 42-3) we see how a century and a half ago (1862) prejudices on identity and nationality shaped the medical practice: since the patient is “a foreigner, a drunk, and loud” [emphasis original] there is no need to anesthetize him. (In the notes [pp. 99ff.] we learn that the poem was based on the idea that surgeons back then only gave opiates and alcohol “selectively”). Although we could be tempted to think that this speaks of something that only occurred in the past, the poem reminded me of recent published research in the US, which proves that today black people are less likely to be prescribed opiates for pain management than their white counterparts.1

The third section is a compilation of reflections on the passage of time, on life, and on death. Those moments occur around the world, in places like Alaska, Alexandria, Kosovo, or Cambodia. There are poems on the horrors of war (“War Remnants Museum, Ho Chi Minh City” p. 56), on the passage of time (“Deliver Us From Evil”, pp. 64-5), and on the contrast between life and death: in “Cesium 137” (p. 68) we are presented with a scene in Brazil where the same substance that uncovers the “loveliness” of the children (“their loveliness aglow at last”) also causes their death. That substance is the radioactive isotope cesium 137, deadly toxic.

The tone of this section is sharp, direct and often painful, particularly for me the poem “Christmas in Kosovo” (p. 57), an account of the result of the war in the Balkans. The verses unfold the horror of the conflict with brutal clarity:

“One of the men was found in the courtyard,

decapitated, and so far his head

remains missing. Many had been shot

at close range, after the solider pricked them

with machetes and brass knuckles. Later,

the women were raped, and in some cases

their bones were broken.”

That strongly contrasts with the moment in which the poet is witnessing those horrors (soon after Christmas): a time of hope for the coming of Christ, to which Coulehan alludes through the reference to Isaiah’s “Prince of Peace” (Isa 9:6 “For a child has been born for us, a son given to us; authority rests upon his shoulders; and he is named Wonderful Counselor, Mighty God, Everlasting Father, Prince of Peace”). That strain between hopelessness and belief, so present in the poem, made me reflect on the very same tension that is often present when coping with a diagnosis of a life-threatening illness.

Finally, the fourth section comprises family memories and meditations on personal experiences. This change of perspective enables the reader to think about health and illness from different angles, gaining a richer and deeper understanding of topics previously considered in other poems. “Fever of Unknown Origin” (p. 79) speaks about the urge to find explanations to events that are often impossible to account for (“I hold to an old script/ that says calamities have reasons (…) Convenient nonsense,/ but sometimes true.”), and about the need to find a cause to gain control over the disease. With the narrator as the patient, the poem is a reflection on the fear of being seriously ill, and the threat that that constitutes to our somehow perceived “ordered” reality.

The exposure and vulnerability that often patients feel while being examined is a topic extensively covered by Coulehan from the perspective of the doctor, but in “Role Model” (pp. 80-1) this matter is beautifully explored from the view of the patient. The detached and factual discourse of the physician contrasts with the feelings of shame of the patient, who just wants to leave and hide away from the clinician: a need that perhaps we have all felt at some point when being exposed in front of a stranger.

Overall, The Wound Dresser is a fascinating journey that takes us through the complexities of life, illness and death; a journey during which the reader has the opportunity to reflect on the tension between the objectiveness that supports the clinical encounter, the doctor’s inner world, and the patient’s humanity, secrets, fears, needs and contradictions. The presentation of clinical encounters, the use of historical figures or events, the look at scenes around the world, and the account of personal memories that Coulehan brings us facilitate a contemplation of health and illness from interesting and varied perspectives, thus enriching the reader’s world and triggering meaningful meditations on the art of medicine.

 

References

  1. Goodnough A. Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder. The New York Times [Internet]. 2016 [cited 15 August 2016];. Available from: http://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?smid=fb-share&_r=0

 

Further Reading

Blackhall, Leslie J., “Cultural Diversity And Palliative Care”, in Chochinov, Harvey Max and William Breitbart (Eds.), Handbook of Psychiatry in Palliative Medicine, 2nd Edition (Oxford: Oxford University Press, 2009), pp. 186-201.

 

 

Poetry and Medicine: Prize Winners

20 Jun, 16 | by cquigley

 

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In April I attended the 7th International Symposium on Poetry and Medicine where the 2016 Hippocrates Awards were announced. A fascinating day, the programme included critiques on Philip Larkin’s The Building, Celia de Freine Blood Debts, Mary Kennan Herbert’s Skin Man series, as well as a presentation on Poetry, Psychoanalysis and Ageing, and a discussion around the evidence for the benefits of poetry for patients. Poetry readings of course dominated the proceedings, not just from winning and commended poets, but also sessions from Rafael Campo and Wendy French. A day truly rich in poetry, it left much to reflect on in terms of the potential for the genre to impact on the illness experience.

Winners for the three categories within the Hippocrates Awards are featured below. These and many other poems selected by the judges are available in the 2016 anthology.

Poems very gratefully reproduced by permission of the poets and the Hippocrates Prize.

 

2016 Hippocrates Prize for Poetry and Medicine

 

NHS First Prize

Denise Bundred (Kitchiner)

 

A Cardiologist Seeks Certainty

I spread cold gel on a newborn chest

rest the probe on creamy skin, angle

between ribs, rotate to find a heart

no larger than the tiny fist

pushing me away.

 

Two dimensions defy translation into three

as I locate chambers

amid the maze of vessels.

A millimeter of movement and the image melts

to snowstorm on my screen.

I re-trace arcs of ultrasound to relieve

the twist of doubt.

Adrenalin dries saliva as I strive to decide

whether the aorta arches

to the left or right.

 

The nurse checks the prescription

against an ampoule, initials in black ink

secure in her certainty of drug and dose.

 

The surgeon weighs my words

to determine his incision

shape his operation

as the incubator trundles towards theatre

escorting mother and the nurse.

 

I resolve inconsistencies

into diagnosis, wipe the sweat

from my hands, write my notes;

make my decision.

 

 

Open First Prize

Owen Lewis

 

At Tribeca’s Edge

This evening, I walk to the water where the Hudson opens

itself to the sea, and the sea with its rough cross-currents

is in the air and in the light—the light spectacular, clear,

illuminates the buildings of Newark across the water-way

with gold. The shimmering gold at their backs, they gather

to watch the harbor—the skiffs, prow-high, skip like kids

on a great lawn, a run-away pair braid ribbons of bridal white.

What will I tell my colleagues, gathering in a nearby auditorium?

 

I am thinking of my students, this first evening of Autumn,

young doctors eager with learning, still saddened by the sick.

The best are afraid. They’ve heard their voices tired, darkened

and hoarse. A ferry glides by, its wake spilling the embankment,

so close it seems we must hitch a ride, step in—and the light

between the distant buildings prying free, the sails opening with light.

 

 

Young Poets Prize

Catherine Wang

 

Six pills

Spread out in line like a
formal salute, phrased carefully on
the glass dining table.
Prednisolone coated in
white powder
as
bitter as a serrated edge. Mycophenolate
always stuck to my tongue,
a thick bullet. Then,
Esomeprazole and Hydroxychloroquine
coated my
insides
with chalk. I swallowed Calcium,
Vitamin D, just to ensure
that my thinning bones
would not crumble
like wet
paper.
There is nothing greater than the
drama of the human body,
its desires, indulgences.

 

Fevers and rashes. There was so
much that sixth grade
science could not
account for.
Lupus
was not a model disease, not a
display easily shown on brown
and pink plastic organs.
I embraced the
liberties of
ignorance,
deciphering my disease through its nocturnal
whispers. Pushed by the wind’s
warm muscles, I probed
the orange membranes
of streetlamps.
I
traced the moon’s breath, lingering on
the black glass of the sky.
Six pills spread out in line.
Head tilted back, I was grateful
for the silence,
for the empty taste of air.

 

Copyright  © 2016 the individual poets.

More information, including readings and excerpts from winning and commended poets, can be found here.

 

Check out the poetry and prose pages in the current issue of Medical Humanities

 

 

PCMD Medical Humanities Conference 2016

18 Apr, 16 | by cquigley

 

Ian Fussell

Community Sub Dean UEMS

 

In 2002, The Peninsula Medical School (now Peninsular College of Medicine and Dentistry (PCMD)) became the first UK medical school to integrate the medical humanities as core curriculum.

Every year since, year four students engage in a six-month project alongside and mentored by an artist. The culmination of the project is a conference organised by the students displaying and presenting their work.

The work thus created has become increasingly sophisticated over the years, as evidenced by the 2016 conference that just took place in Truro (April 2016). In fact, it was probably the highest quality of work seen to date and would not be out of place at any international medical humanities conference.

The morning session was opened by Professor Alan Bleakly, the current President of the Association for Medical Humanities and a leading world expert in the field. This was a particularly poignant conference as 2016 is the final year that it will be run under the auspices of PCMD following the disaggregation of Exeter and Plymouth Medical Schools. It may have been this, or the unsettled future that the current students are facing, that gave this year’s presentations an extra edge.

Following a superb talk by Alan that encouraged a political voice, we were treated to three songs written and performed by “Dull to Percussion”, a band formed in the “Medical School of Rock” module. The songs were indeed political, satirising the split between the universities and included a protest song aimed squarely at our Health Secretary. Search iTunes or Spotify to listen for yourself, and watch “A Song for a Hunt” go viral.

The day was then jam-packed and it was impossible to experience all that was on offer. The range of skill and talent was breathtaking. We were lectured on the human cost of the western desire for sweetness by students from the anthropology module, and invited to debate “Do Christians make better doctors” by the Christian ethics students. This year a number of new Special Study Units (SSUs) were run. They were also extremely good and included a collaboration with Truro’s Hall for Cornwall team.

The students worked at the theatre, but more impressively wrote a play on mental health in medical students. We were treated to a premiere performance – “Permission to be Human” should be performed at every medical school in the country. There was also a monologue by a shy mature student who helped us understand alcoholism and PTSD in war veterans. The mood was lifted by a hilarious stand up routine; how can dislocating your shoulder be so funny?!

There were a number of writing modules, including poetry. The audience was encouraged to write poems in a short workshop. Another new module was “Writing the Knife”, which generated superb short reflections on memorable clinical incidents. One piece called “Quayside” was outstanding and deservedly won a prize. Read it here https://memorablemedicmoments.wordpress.com/author/memorablemedicmoments/ and add your comments.

There was so much more to the students’ work, and this short piece cannot cover everything. However, I do want to mention a some other excellent pieces: working with clay exploring the professional masks doctors wear; pottery boxes representing the mess that doctors get into as they progress through their careers; moving and uncomfortable films that depicted a child’s journey through a hospital; the doctors strike shown as a frightening political movement; dopamine photography; a project on how we smell; and life drawing in conjunction with Falmouth Art School. At the end of the day we were “kettled” into a small room, and forced to party…

The aim of this SSU is to develop student’s tolerance to ambiguity. But the SSU achieves much more than this: it helps students develop a community of practice; it also fosters development of resilience and peer support; and importantly, the students have fun while exploring other perspectives on life and illness. I am extremely proud of our medical students and feel very privileged to work with them in this way. I hope that both Exeter and Plymouth continue with medical humanities in their developing curricula.

 

 

 

The Reading Room: Short-list for the 2016 Hippocrates Prize for Poetry and Medicine

22 Mar, 16 | by cquigley

 

Fragility of the human form: short-list for the 2016 Hippocrates Prize for Poetry and Medicine

 

The Hippocrates Initiative for Poetry and Medicine – winner of the 2011 Times Higher Education Award for Innovation and Excellence in the Arts – is an interdisciplinary venture that investigates the synergy between medicine, the arts and health.

Poets from New York and the UK are among the finalists for this year’s prize. Short-listed in the Open Category are Owen Lewis, child psychiatrist and poet from New York, and from the UK poets Anne Ryland from Berwick-on-Tweed and Jane McLaughlin from London.

Competing for the UK NHS 2016 Hippocrates first prize are paediatric cardiologist Denise Bundred from Camberley, former consultant haematologist Karen Patricia Schofield from Crewe and GP Chris Woods from Bury.

Find out more about the shortlisted poets.

The judges also agreed 16 commendations in the NHS category, and 17 commendations in the Open International category from Australia, France, England, Ireland, Scotland, New Zealand and the USA.

Find out more about the commended poets.

The winners will be announced at an awards ceremony in London on Friday April 15, 2016.

Check out the Medical Humanities poetry section here.

 

 

Ayesha Ahmad: Introduction to Global Humanities—Through Creation, Violence Will Die

15 Mar, 16 | by Ayesha Ahmad

Against the backdrop of violence, I have been examining through my research the qualities of our human condition that perpetuate both our survival and our spirit.

As an introduction to an ongoing series on Global Humanities, I will be discussing ways we can counter the dominant narrative of violence.

Our globalised world, or rather, the collective ‘Other’, is met through encounters from suffering—the patients that enter our clinical settings, the individuals that sacrifice their lives to reach the shores of safety, and the images that we only ever see from afar of stories that breathe suffering.

more…

5th International Symposium on Poetry and Medicine at the Royal Society of Medicine, Wimpole Street, London on Saturday 10 May 2014

17 May, 14 | by BMJ

Reflections from the 5th International Symposium on Poetry and Medicine by Clare Best

 

This year’s Symposium invited us to focus on how we might begin to define the term ‘medical poetry’ and asked if that is even a useful aim. Michael Hulse started the day with a thought-provoking talk proposing that the Romantic ego has evolved and survived in the area of medical poetry whereas it is now rare in other contemporary poetry. He argued that the natural successors of the Romantic poets, those foregrounding the self in extremis, are concerned with what he terms ‘primary medical poetry’ –  in which a person writes about his/her own experience of illness or treatment from the point of view of an existential self. ‘Secondary medical poetry’ is the term Michael used to describe poetry written about medical experiences happening to a close other. He saw ‘tertiary medical poetry’ as including poetry that stands at another remove from the medical experience, being more engaged with scientific, historical, ethical and other aspects of medicine.

 

Michael’s talk was a helpful starting point, and throughout the day speakers came back and back to the different kinds of medical poetry he had suggested. After years of hearing nothing but the term ‘confessional poetry’ used in reference to poetry of extremis written in the first person, I liked Michael’s idea of affirming ‘a central literary site’ for the Romantic ego.

 

A particular highlight of the Symposium, for me, was Sandy Goldbeck-Wood’s beautifully fluent and convincing presentation of her work on how biography drives biology. I have always been interested in how the body expresses adverse experiences as symptoms, and I found myself nodding as Sandy spoke about how ‘both poetry and psychosomatic illness might be seen to be forms of embodied feeling or knowledge, both resisting “purely conscious” forms of communication’. Yes!

 

There were many, many other highlights, including Alan Beattie’s warm and generous account of Norman Nicholson’s life and poetry, Ahmed Hankir’s powerfully dramatic rendition of his ideas around the wounded healer, and Jens Lohfert Jorgensen’s brilliantly engaging presentation of the Danish poet Morten Sondergaard’s Wordpharmacy (do have a look at http://www.wordpharmacy.com) – I’ll be ordering my copy immediately.

 

Then there was poetry itself of course: poems of medicine and surgery, remedy and reverie, diagnosis and prognosis, all kinds of poems to make you laugh and cry. I was honoured to present some of mine from Self-portrait without Breasts alongside Rebecca Goss reading vivid and beautiful poems from Her Birth and Lesley Saunders reading from her stunning collection Cloud Camera.

 

Philip Gross gave gorgeous readings from Deep Field and Later, leading us on into the final part of the day which celebrated the winning and commended poets in the three categories (Young Poet, NHS and Open Awards) of the 2014 Hippocrates Prize for Poetry and Medicine. Conor McKee won the Young Poet section with ‘I Will Not Cut for Stone’, Ellen Storm won the NHS section with ‘Out of Hospital Arrest’ and Jane Draycott won the Open section with ‘The Return’. Many congratulations to all the winning and commended poets.

 

I came away from the Symposium once again inspired and uplifted by the truth and power of poetry that addresses medical subjects. I came away knowing that in the face of extreme and threatening medical events, in situations where our identities are challenged and even deconstructed or changed forever, poetry can excite us into new appreciations of life and of who we are and can be. As I see it, the more science probes and uncovers the physical and medical experiences of our lives, the more we need poetry to interpret and express these experiences. Poetry and medicine are perfect companions.

 

Thank you Donald Singer, Michael Hulse, Nicola Williams and all the others including the judges Sarah Crown, Robert Francis QC, Philip Gross and Kit Wright, who made Saturday happen. It was a wonderfully rich day. I’m already looking forward to next year’s Symposium.

 

Find out more about the Hippocrates Initiative for Poetry and Medicine at: www.hippocrates-poetry.org

 

Clare Best

www.clarebest.co.uk

http://selfportraitwithoutbreasts.wordpress.com

 

 

Guest Blog Post by Poet and Writer, Clare Best, Part 2: On Scars and Memories

21 Apr, 14 | by Deborah Bowman

Guest blog for BMJ Medical Humanities by Clare Best

 

Recently I’ve been thinking about cutting/editing and scars/memories. In two linked pieces for the BMJ Medical Humanities blog, I take a look at my own relationship first with knives and cutting and then with scars and memories.

 

Part two: Scars and memories

 

If I, as a former artist-craftswoman and as a writer and editor, am some kind of surgeon, then surgeons are also editors and writers. They arrange and rearrange our anatomies, cutting away what is not healthy, what is no longer required, repairing what is not working as it should. They invent and create new mechanisms and implant them into our bodies. The aim of most surgery, it seems to me, is to alleviate suffering and allow bodies and human beings to function as fully as possible. Surgeons facilitate – as far as they are able to – our wholeness. Our bodies, subjected to their hand work, become altered and edited versions of our earlier, or first draft, selves. Surgery is one agency in the mutability of human experience.

 

My own body has been revised and edited in many ways, as of course have all human bodies – by growth, by accidents, by disease, by ageing and even by self-harm, as well as by surgery of various kinds. In my case, the most dramatic revision and editing happened in 2006 when I underwent elective double mastectomy as a way of reducing my risk of contracting a hereditary breast cancer in my mother’s family.

 

I have written elsewhere about the decision-making journey leading to my surgery, as well as about the creative processes that sustained me before, during and after surgery – the creative processes which later developed into the project Self-portrait without Breasts (http://selfportraitwithoutbreasts.wordpress.com). Here, I want to think about scarring as evidence and reminder of trauma and loss. And I want to raise questions about the ways in which scars are read and interpreted – both as signs of surgery and as memorial sites.

 

The surgeon who operated on my mother was a kind and gentle man who nonetheless believed in radical mastectomy, which involved removing not only all the breast tissue but also much of the underlying muscle of the chest wall, and all the lymph nodes. Considering that the particularly aggressive nature of inherited breast cancer was not recognised in the 1970s (when my mother’s cancer was first found) she was lucky to encounter a surgeon who believed in this approach. Her radical mastectomies five years apart, following multiple primary tumours in both breasts, almost certainly gave her the additional twenty-five years of life she enjoyed until she died in her early seventies. But the resulting scars, both visible and invisible, were terrible to her. She never wanted them to be known about, let alone witnessed. She and I were very close, and yet throughout the many times I nursed her, and right up to the end of her life, she made enormous efforts to keep her morbidly scarred torso and upper arms from my sight. I saw the scars only twice, on both occasions by accident.

 

My mother was not unique in her shame and suffering. Although we now find it hard to imagine a world in which the words ‘breast cancer’ were unspeakable, that was the world my mother, and countless other women, inhabited. With the prominent outer features of their gender and sexuality invaded by disease and/or surgically removed, women with breast cancer struggled to maintain a sense of identity. But by the same token there was no language in which to talk about their loss and fear, and the scars had to remain unseen, both literally and metaphorically.

 

So taboo was this disease, in the world and in our family, that when my first cousin was diagnosed with aggressive ductal carcinoma in the mid-1990s, she had no knowledge of her aunt’s (my mother’s) experiences, even though her own mother (my mother’ sister) had also developed breast cancer. It was only when my cousin and I began to correspond about our mothers’ breast cancers that the extent of the deeper family scarring became visible and tangible. We began to read the scars and interpret our own situation, the risks we faced. We could also finally perceive the scars in our mothers’ generation as the memorial sites they were – places where loss and pain should have been respected, remembered and properly grieved, instead of turned away from and covered up.

 

The good news is that the current climate around surgical scarring is much more open. This has to be a very positive change for individuals and for society. Some of the mainstream breast cancer charities such as Breast Cancer Care are now running campaigns that address body image issues with photographs of women at ease with, and baring, their scars. The recent Under the Red Dress project has drawn a groundswell of support for making scars visible, even legible, and the project clearly links that legibility with raising awareness of breast cancer. My own work explores and extends the ways we tell the stories of our bodies; in speaking out through poetry and photographs, I speak for other women in my family and beyond.

 

But there is more work to be done. If scars are both evidence of cutting/editing and sites of memory, we are presently at risk of overemphasising the evidence whilst sometimes failing to properly acknowledge the memories. A recent statement from Judy Kneece, sent around social networking sites by the (American) National Breast Cancer Foundation, asserts that ‘Breast cancer has invaded my body, but it need not invade my spirit. There may be scars on my chest, but there need not be scars in my heart.’ Apart from the use of the stale military terminology by which all experiences of cancer seem to be set up as battles to be lost or won, the core of the message is, I think, distressing in its denial of the need to admit inner wounding and thereby begin to integrate trauma and loss. Of course the scars are in the heart as well as on the chest – how could it be otherwise, and what is wrong with that?

 

We should seek to accept the hand work – the cutting – where it is necessary, and treat with tenderness and care the consequent scars and the memories they represent. Surely this honouring of the memory as well as the scar, the material edited as well as the knife and the cut, makes the move towards true healing both more imperative and more likely.

 

Clare Best is a poet and writer with particular interests in writing body and landscape. Her poems are widely published in magazines including The Rialto, The London Magazine, Magma, Resurgence, Agenda and The Warwick Review. A chapbook, Treasure Ground (HappenStance 2009), resulted from her residency at Woodlands Organic Farm on the Lincolnshire fens. Breastless – poems from the sequence Self-portrait without Breasts with photographs by Laura Stevens – came out with Pighog in 2011, and Clare’s first full collection, Excisions (Waterloo Press 2011) was shortlisted for the Seamus Heaney Centre Award. She teaches Creative Writing for Brighton University and the Open University, and lives in Lewes, Sussex.

www.clarebest.co.uk

http://selfportraitwithoutbreasts.wordpress.com

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