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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)


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.



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


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

Film Review: X + Y

13 Sep, 16 | by cquigley


X+ Y- UK, 2014, directed by Morgan Matthews

Reviewed by Dr Khalid Ali, Screening Room Editor


Books, films and plays exploring the Autism Spectrum Disorder (ASD) have traditionally met with critical acclaim; ‘The Reason I Jump’ (, ‘The Curious Incident of the Dog in the Night Time’ (, and ‘Rain Man’, USA, 1988, directed by Barry Levinson ( being notable examples.

‘X +Y’ is a film in the league of cinematic outings inspired by a true story exploring ASD. Nathan Ellis (Asa Butterfield) is a young teenager who was diagnosed as a child with ASD. Following his father’s untimely death in a car accident, he rejects his mother Julie’s (Sally Hawkins) attempts to bond emotionally. Nathan’s Maths teacher in school, Mr Humphreys (Rafe Spall) recognises Nathan’s gift for numbers, and offers to mentor him in the preparations to be a member of the UK team for the International Mathematical Olympiad (IMO). After being selected to represent the UK, a trip to Taiwan forces Nathan to deal with bullying, peer pressure, as well as the woes of first love with a fellow Maths prodigy Zhang Mei (Jo Yang). Nathan starts to reconsider his priorities in life. Is bonding with numbers and calculus theories more rewarding than bonding with humans? Can he transform his teacher’s bleak views on life? Can he reconnect with his mother?

The film is based on the life of Daniel Lightwing who represented the UK in the IMO in Slovenia in 2006, and whose story was first seen in the documentary film ‘Beautiful Young Minds’ ( Being a fiction film, ‘X+Y’ deviates from Daniel Lightwing’s life story in several key areas: the IMO was held in Slovenia, and not in Cambridge, Daniel’s father did not die in a car accident, and his Maths teacher was a woman, and not a man as seen in ‘X + Y’.

The film depicts several common features of ASD (social deficits, communication difficulties, and stereotyped behaviour). As the story unfolds, the viewer is led to empathise with Nathan’s mother in her frustration to understand what is going through his head; his refusal to hold her hand at his father’s funeral, his outburst after getting a Chinese take-away with an even number of prawn balls, and his harsh remarks that she is not ‘clever enough’. Obviously one film cannot cover all issues relating to the complexity of a family’s reactions to raising a child with ASD. However, ‘X + Y’ does go a long way towards shedding a light on analysing the feelings of guilt, as well as on the self-doubt that some parents experience. Such themes were similarly dissected in more detail in the UK TV series ‘The A word’ (

Through imaginative use of light and sound, the film convincingly demonstrates the phenomenon of synaesthesia, where stimulation of one sensory pathway leads to an automatic and involuntary experience in a second sensory or cognitive pathway: Nathan’s mathematical puzzles are thus transformed in his brain into shapes of bright colours. His outstanding mathematical skills make him a ‘savant’; however this gift does not bring him happiness or contentment. Nathan’s isolation is felt even amongst his peers at the Maths camp in Taiwan. Having a gift for numbers can be a curse as well as a blessing – being totally absorbed in the world of numbers alienates the ‘synaesthetist’ child from his school peers – he/she is perceived as the school nerd/geek who most kids avoid and ridicule.

With its heart in the right place, the messages that ‘X+Y’ conveys – an understanding of people who are different, promoting tolerance and empathy – are welcome. However, it risks perpetuating the notion that children with ASD have to be exceptionally talented to be accepted by society, what Nathan’s companion in the Squad team describes as ‘If you (someone with ASD) have the gift, you will be called ‘gifted but weird’, but if you don’t have a gift, you will be labelled as ‘weird’ only’.

The viewer potentially struggles with too many plots – Mr Humphrey’s problems with MS, drug addiction, and social isolation warrants an entire film alone. Nathan’s story has a happy ending, and provides a crowd-pleasing moment, but it underestimates the harsh realities lived by children and families affected by ASD. Still, it is a welcome piece of film making that is both moving and brave in its depiction of what it feels like to be diagnosed with ASD.

Address for correspondence:




Poetry Book Review – Cancer Poetry

10 Sep, 16 | by cquigley


Ian Twiddy, Cancer Poetry. Palgrave Macmillan, 2015

Reviewed by Sue Spencer


Cancer remains one of the most feared of diseases. It evokes dread in the general public and stimulates startling headlines about its insidious and destructive nature. Even as knowledge increases and cancer detection rates improve, this remains the case, despite the fact that cancer is now more treatable and curable than ever. Given this shift in experience of cancer, I had hoped that Cancer Poetry might provide an insight into how poets and poetry have helped humankind navigate this tricky terrain – a big ask I realise, but I do believe that poetry has the potential to achieve this.

I looked forward to reviewing this book. As a nurse, an educator and a writer, I am committed to improving patient experience of health care. I believe that creative approaches can be very powerful in terms of bridging the gap between patients and professionals in the clinical encounter. I am committed to Julia Darling’s project of promoting poetry within this arena. Julia’s introduction to The Poetry Cure, where she shared her own experiences of writing poetry whilst being treated for breast cancer herself, exhorts the benefits of poetry in health and illness:

 “I believe that poetry can help you make you better. Poetry is essential, not a frill or a nicety” (1)

Knowing Julia, I also know that she did not see poetry as an elitist enterprise. She created spaces where wonderful poetry could be responded to in an accessible and enabling way. However, the poetry world does have a problem with being perceived as elitist, with discussions around poetry sometimes viewed as alienating and “other worldly”. Many people I encounter do not often see the relevance of poetry to clinical practice until they actually experience its alchemy and find out for themselves how metaphor, metonym, rhythm, patterns of speech and language itself can shed light on the everyday, particularly in the context of health care practice.

I have to confess to finding Cancer Poetry a difficult read, and found myself skipping significant chunks where it did not engage me. I found the author’s sweeping generalisations and unsubstantiated comments particularly irritating. There are no references to psychological and sociological literature that might illuminate what might be “going on” in a poet’s work.

My first question relates to the inspiration behind this book. Why it was written? Was there an intellectual or emotional impetus to analyse this subject? My personal feeling is that Cancer Poetry reads as an intellectual exploration, in contrast to work such as that of Julia Darling, which, by encouraging us to confront raw emotions and to deal with contested realities, establishes the potential for poetry to help patients and professionals during demanding treatment regimes. Cancer Poetry is a dense book, with an undoubtedly rich content, but I struggled to grasp its potential within the context of improving the experiences of people living with cancer and its treatment.

The opening chapter attempts to chart the terrain, but seems to end up being more of a celebration of Paul Muldoon and his work. There appears to be an ambivalence about whether cancer should be written about and a reluctance to state a position as to whether it is a worthy subject and whether “good” poetry results. There is also a limited review of the foray of other disciplines into this subject – for example, the role of linguistic scholars and the pervasiveness of the war metaphors used to present people’s experiences of living with cancer. I disagree with the author when he states that a similar language is not used in the discourse around other conditions – we hear of ‘wars’ on obesity, people ‘battling’ neurological degeneration etc.

The opening chapter discusses high profile survivors and battlers of cancer, for example Jane Tomlinson and Lance Armstrong, but all of this misses the point that these “celebrity” patients are not typical or representative of most people’s experiences.

The chapters that follow are categorised around specific themes and this is where I found more traction and some engagement in relation to the discussion. However, I would have liked to have known why the author chose the poets that he did. After all, there is a huge body of poetry written about cancer experiences from a range of perspectives and the analysis in this book seems partial and limited. There is also little discussion of the poems in the context of the poets’ other works. It can be very narrow to discuss poems solely on the subject they explore rather than within the landscape of a poet’s other work or within a historical or cultural context. People’s experiences of cancer are often shaped by their health care encounters, cancer treatments and their side effects, relationships with health care professionals, and ongoing uncertainties around choice and prognosis. All of this must inform poetry written on this subject, yet I found myself not being able to grasp the arguments presented in Cancer Poetry.

This book represents all that I find difficult and challenging in the world of medical humanities. For me, Cancer Poetry is not an example of a melding of knowledge and theory. It is a book of literary criticism on poems written about cancer. I may be wrong, but if we want to engage health care practitioners in the merits of the humanities, to enhance their practice we need to focus less on intellectual silos and more on making connections, sharing insights, creating synergy and stimulating new thinking. I wish this book had done that.



  1. The Poetry Cure edited by Julia darling and Cynthia Fuller 2005 BloodAxe Books

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.




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.



  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:


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.



Film Review: Arab Film Festival

5 Sep, 16 | by cquigley


Both films reviewed below will be screened at the upcoming Safar Arab Film Festival at the Institute of Contemporary Arts London, September 14-18



Before the Summer Crowds, Egypt, 2015, directed by Mohamed Khan

Opening night film for Safar, Institute of Contemporary Arts (ICA), London, 14th September 2016,

In Arabic with English subtitles.

Reviewed by Professor Robert Abrams, Professor of Old Age Psychiatry, Weill Cornell Medical College, New York.


The first thing one can say about Mohamed Khan’s acidly satiric film Before the Summer Crowds is that, notwithstanding its title, it is uncommon summer fare. It is neither light nor breezy, and there’s not much of a plot. The principal characters comprise a trio of clueless, seemingly harmless upper-class individuals who have moved into their “chateaux” in the Egyptian beach vacation community of ‘Blue Beach’ before the regular season has begun. But the viewer is not allowed to retain this initial impression of their harmless existence for long; we are soon let in on the shockingly extensive roster of evils that lies beneath their casual banality: Infidelity, gluttony, corruption, spiritual emptiness, indifference to life, and even a taste for carnage.

First, there’s the pudgy Dr. Yehia (Maged El Kedwany), a man preoccupied with food and sex, whose private hospital scandalously reaps profits by understaffing its medical ranks and hiring inexperienced physicians. Even when he performs a supposedly life-saving cardiopulmonary resuscitation on a beautiful young woman, it is clear that his own sexual gratification is being addressed simultaneously. Yehia’s wife Magda (Lana Mushtaq) is the very personification of emptiness, attempting to sate that void by gorging herself on peanut butter. Magda owns an inherited chateau—a facetiously pretentious name for a beach cottage–in the ‘first row’ of the seaside community, a distinction of which she is inordinately proud and one that she believes places her apart from the ordinary parvenus who arrived at ‘Blue Beach’ more recently. Magda tolerates Yehia, but there is no sense of love between them, not even lust. We see Magda meditating, but there’s nothing spiritually meaningful about what she does—her mind is already empty.

In the course of the film, Yehia becomes involved in a mutual attraction with Hala (Hana Shiha), a young mother who is uninterested in her children and uses her chateau as a trysting place for a rendezvous with Hesham (Hani El Metennawy), her narcissistic B-movie actor-lover. (This fact gives a rather smarmy double meaning to the name ‘Blue Beach’). When Hala learns that Hesham has been unfaithful—no great surprise—she finds common ground, albeit on very shallow soil, with Yehia. They flirt with the idea of having an affair unbound by any conscience or moral codes.

Yehia is at once grotesque and immature, but one is gradually made to understand that his immaturity is far from victimless. His patients are cheated, a court case of medical negligence case is underway; his wife is cheated on; and he sleeps drunkenly as Magda’s pet parrot—the only creature she seems to love—is set upon by cats. It is not the feline hunting instinct that is highlighted in that scene of carnage but Yehia’s indifference. Even Yehia’s preparations for a festive dinner with freshly caught fish seem more like a bloody massacre and an extravagant waste of marine life than a demonstration of his culinary skills.

The working-class young man, Gom’aa (Ahmed Dawood), the resort bell-boy, is seen by Yehia, Magda and Hala as a dispensable entity to be treated with barely hidden condescension. Gom’aa is mainly useful for errands, watering the garden when Yehia doesn’t feel like doing it himself, and fetching things for Hala.

Not a great deal happens in Before the Summer Crowds; but it somehow leaves the viewer with a surprisingly strong impression of sadness and regret. All of the characters are presented as prisoners in different ways of this gated community, unable to move beyond its strictures. The only exception is Gom’aa, a young man who comes from another world looking for his ‘Shangri-La’ in ‘Blue Beach’. Yehia, Magda and Hala have material abundance, sex and food, but are utterly bereft of passion or purpose. The lives of these principals—again save for Gom’aa—are so pathetically empty and loveless that the compassion of the viewer for these otherwise contemptible individuals is paradoxically elicited. How? The key is in the extraordinary acting, where we are unwittingly induced to experience emotions that should belong to the characters but do not; in a way, it might be said that this is the hallmark of all excellent acting.  Here, in the subtly played role of Dr. Yehia, Maged El Kedwany ( demonstrates why he is considered one of the finest contemporary character actors in the Arab world. Although I have been told that Before the Summer Crowds is not typical of the films of the late Mohamed Khan (, this deceptively non-action film skillfully not only skewers the bourgeois vacationers of Blue Beach for their corruption and emptiness, but it also lets us feel the sadness of their lives.

Address for correspondence:


Borders of Heaven, Tunisia, France, United Arab Emirates, 2015, directed by Fares Naanaa

ICA, London, Saturday 17th September 2016

In Arabic with English subtitles

Reviewed by Dr Khalid Ali, Screening Room editor, Medical Humanities


Recently, Tunisian cinema has become an artistic force to be reckoned with, As I open my eyes winning best director for Leyla Bouzid in Dubai International Film Festival 2015 (, and Hedi opening Berlin Film Festival in 2016 ( Borders of Heaven is another compelling story from Tunisia written and directed by Fares Naanaa.

Samy (Lotfi Abdelli) and Sara (Anisaa Daoud) are a happily married couple with their little daughter Yasmine (Sophie Ghodhbane). Their blissful existence is shattered when Yasmine dies in a drowning accident. Samy is consumed with guilt as he blames himself for Yasmine’s death. Losing the will to live, he wanders aimlessly seeking solace in illicit affairs with random women he meets in the streets.

On the other hand, Sara is determined to fight for survival and a meaningful life in spite of her inconsolable grief. She continues to work daytime and rehearses singing every night with a music group. Sadly, Samy and Sara have become strangers in their household; she wants to re-build their married life, while he is entrapped in his world of anger and hopelessness.

Josephine Jacobsen ( described the devastating effect of a child’s death in one of her poems: ‘’It is a fearful thing to love, what death can touch’’. Borders of Heaven revisits the universal themes of isolation, grief and bereavement after losing a child; themes that were explored in Don’t Look Now, UK, Italy, 1973, directed by Nicolas Roeg, (, and Rabbit Hole, USA, 2010, directed by John Cameron Mitchell ( In Don’t Look Now the bereaved couple indulge in an intense sexual relationship to distract their minds from grief, while Samy indulges in alcohol and one-night stands. The estrangement and bitterness that Samy and Sara experience are reminiscent of another bereaved couple’s ordeal (Nicole Kidman and Aaron Eckhart in Rabbit Hole).

Fares Naanaa reminds us of the Kübler-Ross model of the ‘Five stages of grief: denial, anger, bargaining, depression and acceptance’ (1, 2). While Samy is stuck in depression, Sara has accepted the reality of losing her daughter using music and singing as a means to restore her well-being; a form of ‘personalized music therapy’. Echoing themes of Song for Marion, (UK, Germany, 2012, directed by Paul Andrew Williams,, where salvation for a widowed husband came from his engagement in a community music group, Borders of Heaven emphasises the role of music in healing after loss (3, 4).  Sara demonstrates what mental health professionals call ‘psychological resilience’ (5, 6); she channels emotions and words into a creative outlet. Her identity is one of ‘normalizers’; individuals who focus on connecting with friends and community to re-create meaning in their lives after bereavement, while Samy belongs to the ‘nomads; people who are stuck in anger, depression, and loneliness’ (7). Coping with grief after losing a child calls for desperate measures, which can take the form of ‘disinvestment’ in traumatic memories, and moving on with life, which Samy cannot muster.

Both lead actors, Lotfi Abdelli and Anisaa Daoud, give heartfelt performances displaying raw intense emotions that are rewarded by the viewers fully empathising with their tragedy. It is no wonder that Lotfi Abdelli won best actor award in Dubai International Film Festival, 2015, Borders of Heaven is a universal story of loss, hope and survival.


  1. Kübler-Ross, E. (1969) On Death and Dying, Routledge
  2. Kübler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss, Simon & Schuster Ltd
  1. Khan W U, et al 2016. Perceptions of music therapy among healthcare professionals. Med Humanit 42: 52-6.
  2. Moss H, Donnellan C, O’Neill D, 2012. A review of qualitative methodologies used to explore patient perceptions of arts and healthcare. Med Humanit 38: 106-9.
  4. Bonanno, George A. Have we underestimated the human capacity to thrive after externally aversive events? American Psychologist 2004; 59 (1): 20-8.

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Film review: Julieta

24 Aug, 16 | by cquigley


Julieta, Spain, 2016, directed by Pedro Almodovar

In UK cinemas from 26th August 2016


Reviewed by Dr Franco Ferrarini, Gastroenterologist with a special interest in functional gastrointestinal disorders and their treatment with hypnosis


The opening shot of Pedro Almodovar’s ‘Julieta’ shows a pulsating red cloth that looks like a curtain; as the camera slowly pulls back, we realize that it is actually a lady’s dress. From the outset, we know that we are about to enter one of Almodovar’s favourite arenas, namely the ‘women’s world’. However, ‘Julieta’ is definitely less “Almo-dramatic” than his previous films; it plays as a mystery tale, but there are no victims, no villains and no murder investigation. Nor do we get the usual humour, the defiance and the provocative style that usually permeate Almodovar’s films.

Julieta (Emma Suarez), is a good-looking, well-off woman in her mid-fifties, who is happily planning a vacation with her lover Lorenzo (Dario Grandinetti). Accidentally she runs into Beatriz (Michelle Jenner) who tells Julieta of a recent encounter with Ania, Julieta’s estranged daughter (Imena Solano, Priscilla Delgado and Blanca Parés, at different ages). Julieta abandons her planned journey, and starts writing a diary conceived as a letter to her daughter Ania. Using a series of detailed flashbacks, Almodovar narrates Julieta’s earlier life, starting with her as a 20 year old woman falling in love with Xoan (Daniel Grao) while on a train journey. The two lovers get married soon after their first encounter, and Julieta gives birth to Ania. After Xoan’s death, Ania mysteriously disappears at the age of 18. Repeated attempts by Julieta to get in touch with Ania end in vain. Using a sequence of emotional scenes, Julieta’s feelings of guilt and bewilderment over Anias’ disappearance are poignantly portrayed. Julieta’s torment is masterfully underlined by Lucian Freud’s self-portrait (1985) hanging on a wall in her house, acting as a metaphor for most of Freud’s paintings, the continuous suffering of everyday life.

‘I sometimes have the impression that reality is simply there to provide material for my next film’, Almodovar famously stated. Using imaginative plotting in his films, he underlines the ominous consequences of the unsaid on human lives; the original title of ‘Julieta’ was ‘Silencio’ Spanish for ‘Silence’. A tragic mis-communication between Julieta and Ania, orchestrated by Xoan’s housekeeper, explains Ania’s disppearance, in a plot twist reminiscent of Alfred Hitchcock’s ‘Rebecca’

The role of nature and fate in dictating the tragic life course of some human beings saturate the film. Nature, specifically sea water, bestows both survival means and death (Xoan is a fisherman who dies in his ship during a storm). Fate is at play in the train trip of young Julieta where she met Xoan for the first time: she had just rejected the advances of a depressed passenger (Tomas del Estal), who commits suicide fas a result. We are all at the mercy of fate, with significant consequences stemming from the apparently insignificant choices that we make. But even if we do not make those seemingly trivial choices, fate can cruelly hit, for example with a neurodegenerative illness, such as multiple sclerosis that affects Ava (Inma Cuesta), Xoan’s lover, forcing her to give up a career as a sculptor.

Cognitive loss, as in coma and to a lesser degree in dementia, is also explored: Xoan’s wife has been in a vegetative state for years, and Julieta’s mother Sara (Susi Sanchez) is affected by dementia. Both Xoan and Julieta’s father (Joaquin Notario) react similarly to their wives’ cognitive loss by looking for other women.

A subtle message is appreciated when Julieta visits her bedridden mother who has dementia; talking to her, combing her hair, and helping her get dressed is followed by clear improvement in the mother’s wellbeing.

Almodovar’s hard core enthusiasts may be disappointed as ‘Julieta’ is very different from his previous films. Nevertheless, it can be appreciated as Almodovar’s cinematic development into a more reflective and mature look on life.


Address for correspondence: 

Book Review – In-Training: Stories from Tomorrow’s Physicians

19 Aug, 16 | by cquigley

front cover

in-Training: Stories from Tomorrow’s Physicians by Ajay Major and Aleena Paul. Pager Publications, Inc., 2016


Reviewed by Rhys Davies


In 2012 two medical students from Albany Medical College, New York, Ajay Major and Aleena Paul, founded in-Training, an online forum where medical students could record and discuss their thoughts as they learnt the art and science of medicine. Since then, they have published more than 850 essays, poems and reflections written by medical students. From this, Major and Paul have distilled the finest contributions into one printed collection, in-Training: Stories from Tomorrow’s Physicians.

It is quite a collection. In its dense 347 pages, it covers a wide range of topics and themes germane to medical students and doctors in training, from pre-clinical studies (the book opens with a section devoted to the dissection lab); to memorable patients, their diagnoses and prognoses, their discharges and deaths; to the introspective struggles of medical students such as living up to the image of a physician, work-life balance and professionalism, as well as burnout and mental ill-health; to taking the pulse of systemic ills such as poverty, racism and global health. Essays and prose reflections are intermingled with poetry, and each entry is tailed by a few questions to direct the reader’s own reflections.

Having completed my undergraduate medical education, I initially found this book difficult to get into. While the prose is articulate and well-written, most of the entries hardly struck me as particularly insightful or inspiring. The contributors are all medical students in various stages of training. As such, their reasoning is still a little green, their conclusions perhaps a bit too simplistic and naïve. But to mark this book down for that is to miss the point. This is not, and was never meant to be, an anthology of professional and professorial essays on the witness and practice of medicine. Instead, there is a gestalt feeling of many diverse minds actively reflecting, documenting how they are affected by the business of (learning) medicine.

Many of the situations these student writers touch on and the feelings they evoke are not original. Many doctors and experienced medical students could read this book and say “This is nothing new. This is how I felt then.” However, that would be unfair. Far from pedestrian, this book brings to light the universality of a host of thoughts, feelings and doubts which condense into the single question, “Will I ever be good enough?”

When viewed from the other side, as a fledgling medical student, this book offers solace and encouragement that there are others out there grappling with the same or similar issues. With this in mind, I see how the in-Training website has become so popular. The contributors are all training in the USA. This does distance readers from elsewhere, such as myself, but there is still enough commonality to the experience of medicine and medical school that it does not affect the reading too greatly.

I wrote earlier that a good number of essays in this book re-trod well-furrowed ground, such as the macabre fascination when one first encounters dissection in the anatomy lab transforming into humbling gratitude for their dissected “patient,” or the realisation that the best and most important lessons to learning medicine come not from textbooks but from encounters with real people. While this is true, in-Training: Stories from Tomorrow’s Physicians is at its strongest when its contributors shine a light on more neglected topics. In the chapter focussed on societal ills, leaping of the controversial death of Michael Brown in Ferguson, Missouri in August 2014, one student polemically describes the systemic racial inequalities in US healthcare and challenges readers to examine their subconscious biases and those of the healthcare culture around them. “It is easy to presume that medicine is colorblind (sic), and the care we give a rational process. But cells are not people, and science is not health care. Doctoring is an inherently social discipline…until doctors acknowledge the position of medicine within institutional racism, our health care system will continue to reproduce tragedies like Ferguson, even in the absence of a smoking gun.” This is followed by an essay criticising silence on social justice and issues under the mantle of professionalism. “To be silent in the face of systematic injustices – legislative, medical, social and otherwise – is to be complicit in them. To believe that medicine is an insular, neutral field is naïve…Though it is understandable easier to focus on the medicine because that’s what we’re taught and hired to do, ignoring the injustices both within and outside of medicine does violate the Hippocratic Oath, because silence – real, nearly tangible, oppressive weight – can and does do harm.”

As mentioned earlier, this book is densely packed with essays and poetry, both in terms of themes addressed, and the sheer number of reflections included in the anthology. There is the feeling that Major and Paul would have included even more essays if possible. It is difficult to read through continuously, unlike the reflections and memoirs of a single doctor, because of the constantly changing narrative tone, style and voice. The converse in fact is true, as in-Training: Stories from Tomorrow’s Physicians provides a deep spring to dip in and out of at the reader’s leisure. It is also supremely convenient for tutors of medical humanities and reflective practice to be able pull out selected essays for their students to read, complete with prompts for guided reflection.

Writing in BMJ Careers in June, Dr Daniel Furmedge1 proclaimed that written reflection was dead. Voicing concerns that junior doctors’ reflective entries in their training portfolios at best serve no purpose, and at worst may be used against them by the hospital trust or lawyers, Dr Furmedge foresees that junior doctors in the future will write meaningless anodyne reflections. in-Training: Stories from Tomorrow’s Physicians serves as a corrective against such pronouncements. It details numerous and diverse medical students who have been affected by what they have learnt and seen and done. There is no reason to think they will grow up to be areflective doctors. Written reflection is very much alive.


Dr Rhys Davies

FY2 Doctor, Western Sussex Hospitals NHS Foundation Trust





Related reading

Charlotte Blease. In defence of utility: the medical humanities and medical education. Med Humanities 2016;42:2 103108

Global Humanities – A Refugee in the Clinic

15 Aug, 16 | by cquigley


“You see a war zone, I see my home”


Ayesha Ahmad


“In my land”, you say. I trail away from your story into my own exploration; I am wondering about your possession—about your land, what it means for your to be yours, or what it means for you that my land is mine, and not yours.

In hospitals all over Europe, doctors are practicing medicine on the frontline. The patients are seen as refugees, or asylum seekers, or undocumented migrants; categories that are formed to describe who the person is in relation to their status to the land they are in.

When the phrase “in my land” is embedded in a story of war and displacement, a question is begged: how is a doctor to receive a story of a refugee?

The idea of “my country” represents the host of an individual’s existence. There, in their, and our land, the familiarity that we use to navigate our physical, mental, emotional, and existential worlds can be found.

The language, then, between the patient and the doctor, each from foreign lands to one another, is a script from their books; their poems, scriptures, and literature.

Perhaps in this context of travelling cultures and exploring stories, the need for doctors to understand and respond to stories is the way to close the frontiers between the doctor and the patient, and between the clinic and the home.

Boundaries diminish humanity; they separate ‘you’ from ‘I’.

“My country was such a nice place”, you say when you talk to me about how things were for you. “I am here now, but there, there is my Motherland. Once she was vibrant, but now, now she is like a body in a grave”.

Land, like a person, can become ill. As a victim of violence, a country personifies trauma. The soil, then, is felt like blood in those who are cradled in their births, and deaths, in their land.

Translating the relationship between the land and the body takes time. The transcription takes place using the instrument of reflection to tell a story of “what is in my body now is what I have lived”.

“My body is my land, and my land is my body”.

To treat this severing in the clinic setting, new words and new concepts to add to the body the language of the land are needed.

Bringing forth narratives of a land’s literature and lyrics is a way to represent the person who becomes the patient. The clinic setting marks such a unique centre for the meeting point of cultures—medicine with poetry, storytelling, and narratives that otherwise would remain ‘the Other’ as marginalised and defined by boundaries.

As the humanitarian crises of war and forced displacement dispels and unfolds into the home of doctors, the opportunity to make medicine richer is before us. There is no greater practice for listening skills than to hear a language contain a different land, and an unfamiliar body.

There is new terrain on the horizon for the clinical encounter; new lands to be explored and new narratives to share as the doctor-patient relationship continues to learn how to heal.

“You see a war zone, but I see my home”. As the patient leaves, let us hope that we all see the same place.


Ayesha Ahmad, Global Humanities Editor

Film review: Crying with Laughter

11 Aug, 16 | by cquigley


Crying with Laughter, UK 2009

Written and directed by Justin Molotnikov, available on DVD



Reviewed by Professor Robert Abrams, Professor of Psychiatry, Weill Cornell University, New York


One can debate about what might be the central message of Crying With Laughter, the production with an oxymoronic title written and directed by Justin Malotnikov—a film that is itself both dark and reassuring. In fact there must be several such messages, but to this reviewer, Crying With Laughter is mainly a stirring testament to the therapeutic power of reconstructive memory. However, this assertion requires quite a bit of explanation and reference to the film’s story line. Warning:  massive spoiler alert.

Crying With Laughter opens with screenshots of a hapless failure of a man. Joey Frisk is a thirty-something-year-old Scottish stand-up comedian who is just about always drunk, profane and seemingly bent on self-destruction. He offends nearly everyone in his world, and while he’s loud and brash, he’s not even all that funny as a comedian. He owes money to his landlord, and he’s estranged from his wife. He’s the living embodiment of Freud’s concept of a “death instinct’—a man driven by a potent if unconscious current of self-defeat. He becomes human and grounded only in the moments when he lovingly and protectively embraces Amy, his sweet 6-year-old daughter.

Soon he is in very serious trouble. As part of his comedy routine he threatens the landlord to whom he is in arrears. When the landlord is in fact assaulted within inches of his life, Joey, who has no alibi, is the prime suspect. The situation is so dire that the viewer is compelled to wonder: what is it that is driving Joey to drink, to promiscuity and to a succession of ever-greater blunders? Is he just immature, a perpetual adolescent, suffering from arrested development? If there is a particular underlying sorrow or trauma he is re-living, or a past transgression for which he is punishing himself, why does he not see it?

A distinctly sinister former schoolmate whom Joey barely remembers, Frank, now befriends him, giving him and his daughter shelter. Frank then lures a reluctant Joey to a school “reunion”. What Frank actually intends is to kidnap a former teacher and execute revenge for a traumatic past secret. Unfortunately the frail teacher now lives in the throes of dementia. Throughout this encounter, Joey remembers neither Frank nor the old schoolmaster with any clarity.

One of the extraordinary and moving truths in the film emerges at this point: there can be no meaningful punishment of helpless and elderly demented individuals for the misdeeds of their past—not only because the revenge is in itself cruel and an “injustice”, but because its recipients cannot appreciate what is happening, and the whole enterprise has no possibility of providing “closure” for the victim. An unforgettable cinematic moment is forged by the incompatibility between the imagined school-master of the past—intimidating and manipulative—and the present image of a helpless old man. By any measure, the window of opportunity for confrontation has closed, and the belated effort to avenge the wrong only results in a deeper misery for all.

Without disclosing too many details of the secret that connects the three doomed characters for the reader, the film skillfully reveals why Joey had no conscious memory of the troubling past. Justin Molotnikov (film writer and director) has a deeper understanding: the powerful repression of traumatic memory that led Joey to “forget”—except for the fact that the willful sabotaging of his own life happened to have been his way of remembering. Even Joey’s choice of career seemed derived from an effort to neutralize the events that took place years earlier in that school: “I had to be funny”, he suddenly realizes.

Over the course of Frank’s rageful but futile scheming, Joey begins to appreciate the “interior fatality” of self-punishment that he has been living out; what had made Frank bitter had led Joey to become a self-created buffoon. Joey finds out that personal freedom can be gained whenever one’s own truth is uncovered and squarely faced. It might even be said that he has undergone a de facto psychoanalysis, or perhaps only a successful purge of the inevitable residua of traumatic memory: misdirected anger and unwarranted guilt. Either way, Frank has unknowingly given him a gift of incalculable value.

Much of what makes this film so satisfying to watch is attributable to the superb performances of the two principal actors, Stephen McCale as Joey Frisk, and Malcolm Shields as his counterpart in suffering, Frank Archer. Joey is wonderfully relatable, and even at his worst, he is also endearing, naïve and innocent. And who cannot recognize in himself at least a kernel of that self-destructiveness and immaturity that Joey had in such abundance? Frank, whose features are distorted into a permanent grimace, is in his bleak obsession as paralyzed in life as Joey had been, and he stands proxy for the destructive force of unresolved grievance.

However one chooses to characterize Joey’s transformational healing process, by the end of the film he unquestionably emerges as a changed man. He is an adult, a reliable sober citizen, more devoted to his daughter than ever. Few closing scenes could be more beautifully, poetically hopeful: in this one Joey walks, buoyantly and confidently, between neatly ordered parallel rows of trees under the brightest sunshine of his life.

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Book review – Exhaustion: A History

9 Aug, 16 | by cquigley

Tired all the time?



Anna Katharina Schaffner, Exhaustion: A History (New York: Columbia University Press, 2016)

Reviewed by Steffan Blayney


In 2015 in Newcastle-upon-Tyne, a new specialist NHS clinic was launched to deal with what seems to be an increasingly common British malady.[1] Among the most frequent presentations in GP’s surgeries, the health service has even introduced an acronym – TATT – to denote the problem of being Tired All The Time.[2] Surely in our accelerated age of global technocapitalism, with its constant demands on our attention, our energy, and our desires, we are more exhausted than we have ever been. Political and economic insecurity, and the threat of environmental catastrophe, mean that we live in a state of permanent precarity and ambient anxiety, while new information and communication technologies are blurring traditional lines between work and leisure and turning us all into 24/7 worker-consumers. In fact, argues Anna Katharina Schaffner in Exhaustion: A History, we are far from alone in seeing ours as the most exhausted age. Societies throughout history, from the classical period to the present day, have been quick to diagnose their period as uniquely enervating.

Schaffner’s book, the first historical monograph on the subject, examines understandings of exhaustion in the Western world across a period of over two millennia, from classical antiquity to the present day. The structure is both thematic and chronological, with each chapter considering a key concept around which understandings of fatigue have been structured in successive historical periods (‘Sin’, ‘Saturn’, and ‘Sexuality’, for example, providing three consecutive chapter headings). Schaffner develops what is essentially a continuity thesis. Contrary to those who would paint exhaustion as a particularly modern obsession, she argues, concerns about the relationships between human energy and human civilisation have been a consistent preoccupation of societies stretching back to Ancient Greece.

Exhaustion, Schaffner observes, has typically been understood not only as a physical, mental or spiritual state, but as a broader cultural problem. Physical symptoms such as fatigue, lassitude, and weakness, and their emotional counterparts of weariness, disillusionment, and apathy, have been matched on the cultural side by concerns with decline, decadence, and degeneration. With a background in comparative literature, Schaffner is at her most compelling in her analysis of language and in the wide-ranging discussions of literary texts (or films) which accompany each chapter. Analogy and imagery, she argues, have been unusually central to the science of exhaustion, structuring not only medical conceptualisations, but experiences of patients and forms of treatment. While scientific definitions of energy and fatigue have remained elusive, rich languages of metaphor have developed linking body and mind, culture and society.

From Galen to Freud and beyond, Schaffner argues, medical writing on exhaustion has been characterised by an ambivalent relationship to modernity. Fatigue diagnoses have often been used to pathologise social, cultural and technological changes deemed problematic by their originators. The American physician George M. Beard, who popularised the diagnosis of neurasthenia in the nineteenth century, famously listed ‘steam power, the periodical press, the telegraph, the sciences, and the mental activity of women’ (92) as the chief reasons for an epidemic of fatigue, while in the twentieth and twenty-first centuries, the decline of traditional social structures and the rise of a new self-involved individualism have been called upon to explain the rise in syndromes such as ME or chronic fatigue syndrome (CFS), pejoratively referred to in the press as ‘yuppie flu’ or ‘lazy cow syndrome’ (184). While arguments about the exhausting tendency of our society are often found in left critiques of capitalism and globalisation, Schaffner argues, the structure of the argument is typically conservative, relying on the imaginary evocation of some prelapsarian age of nature, tradition, stability, and rest, which is supposed to have been disrupted or corrupted by modern developments.

Schaffner’s ambitious time-span allows her to make a number of illuminating comparisons between periods not usually studied together. While the material covered in individual chapters will mostly not be new to medical historians of each period, there is a lot to be gained from taking the broad and comparative perspective that Schaffner attempts. Such an approach, however, is not without its problems. As with other recent historical works which have sought to examine the career of certain medical phenomena through time – for example, pain, depression, or psychosomatic illness – there is an important ontological question that requires addressing. How can we be sure, in comparing or concatenating concepts and diagnoses separated by time, place, and language, that we are really writing the history of a single thing or idea? Once we decide upon our object, we run the risk of finding it wherever we choose to look, imposing present-day concepts onto periods in which they are unfamiliar or inappropriate.

While Schaffner is alert to shifts in language, meaning and diagnosis over time, she nonetheless asserts a universal significance to exhaustion as a concept which dramatizes ‘our darkest primordial fears’ as human beings (13). While the particular metaphors and ideas marshalled to understand exhaustion are historically specific, she argues, there are nonetheless ‘transhistorical psychological factors that determine an ongoing interest in the phenomenon’ (12). Such psychological universalism will be controversial among historians of the human sciences, many of whom would argue that human psychology is itself the product of social and historical shaping. Historians of medicine will also question the analytical utility of Schaffner’s penchant for retrospective diagnosis of historical (or literary) characters, and of her at times uncritical “translation” of extinct medical classifications into present-day terminology. Can we really describe the classical theory of the humours, for example, as ‘proto-biochemical’ (21), or the behaviour of Jason in the Argonautica as ‘characteristic of manic or bipolar depression’ (28)?

Schaffner’s argument leads her to emphasise continuity over change in her narrative. While each chapter records the emergence of new historically- and culturally-specific conceptions of exhaustion, the mechanisms of change and divergence are undertheorised. Despite engaging with an impressive breadth of primary material, the chronological and geographical reach of her study means that Schaffner is necessarily forced to rely on secondary literature to contextualise her sources. The result is a book which, while perceptive and often original in dealing with individual texts, is set within a somewhat conventional view of the history of medicine as a succession of explanatory paradigms. It will be up to other historians to see how Schaffner’s broad arguments can be complicated and refined by case studies more circumscribed in place and time.

Exhaustion is very much a history ‘from above’. The story of fatigue is told through the writings of doctors and intellectuals, with the medical orthodoxy of each historical period typically characterised through the ideas of one or two canonical figures. Only in the later chapters (addressing the twentieth and twenty-first centuries) is there any sustained discussion of exhaustion as subjective or lived experience. Likewise, as Schaffner admits, the forms of pathological exhaustion studied in this book are near-exclusively associated with the middle and upper classes. Proletarian forms of exhaustion – for example the “industrial fatigue” which exercised governments and employers in Europe and America in the first half of the twentieth century – are near-absent. Working-class exhaustion is worthy of its own history, as are the important and consequential contributions made to the medical science of fatigue in the pursuit of industrial efficiency. Here again, it can be hoped that Schaffner’s intervention will act as a stimulus to further study.

Overall, Exhaustion is a timely contribution to a neglected area of study, situating present-day concerns about technology and progress, work and leisure, and the body and society within a long history of medical and cultural writing. Schaffner is throughout engaged with contemporary debates, leaping deftly from Hippocrates to Occupy, or from Proust to Piketty, with a clarity of expression and ease of style that will make Exhaustion attractive – and accessible – to a wider readership. In her epilogue, Schaffner brings the concept of exhaustion to bear on the question of climate change –  a problem, she argues, that unlike other worries about exhaustion, is unique to our own historical moment. Fears about the depletion of the planet’s limited resources of energy and materials mean that we are forced to confront the problem of exhaustion not just at the level of mind, body, or society, but as a threat to our environment and our existence. While all societies have been preoccupied with exhaustion, Schaffner concludes, it is only in the present day that it has become an issue of genuinely apocalyptic significance.


Steffan Blayney is a PhD student at Birkbeck, University of London. Twitter @SteffanBlayney.





Related reading

K G White. Jane Austen and Addison’s disease: an unconvincing diagnosis. Med Humanities 2009;35:98100

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