University of Birmingham, United Kingdom (Summer 2013)
In a letter to Benjamin Bailey in 1817, John Keats, who only one year prior was a medical student himself, wrote: “I am certain of nothing but the holiness of the heart’s affections and the truth of imagination – what the imagination sees as beauty must be truth.”1 This proclamation can be taken as a view of the role of art in the search for truth—the pursuit of truth about the human condition through acts of imagination such as reading literature, viewing a painting, or listening to music. In the search for the truth in medicine we take the need for science as readily apparent, but the role of art is less clear. It is evident that the medical and clinical sciences should be taught and learnt systematically and in depth. However, a purely bio-scientific model of medicine neglects the ethical and artistic dimensions involved with patient interactions, offering a limited view of human illness. This view has led to the increasing acknowledgement that the arts are of value in medical education, coinciding with the burgeoning field of medical humanities in which literature plays an important role.2 This essay explores the benefits of literature to a medical student. Arguments exploring this notion are presented and discussed below, illustrated by texts including Allan Bennett’s A Life Like Other People’s, Charlotte Perkins Gilman’s “The Yellow Wallpaper,” and poems by Phillip Larkin such as “Heads in the Women’s Ward.”
Patient perspectives and empathy
Patients are complex human beings that experience problems within a plethora of contexts, emotional and existential. To provide the best care future doctors need to be able to appreciate these multiple personal dimensions. If a medical student’s own personal frame of reference proves insufficient then literature can offer fresh perspectives. As T.S. Elliot observed “we read many books, because we cannot know enough people.”3
In Phillip Larkin’s poems “Heads in the Women’s Ward,” “How,” and “The Building,”4 we are reminded of how alien and terrifying hospitals and illness must be for patients and relatives. In “Heads in the Women’s Ward” Larkin describes the experience of being on the ward and the thoughts on ageing and mortality that this generated:
On pillow after pillow lies
The wild white hair and staring eyes;
Jaws stand open; necks are stretched
With every tendon sharply sketched;
A bearded mouth talks silently
To someone no one else can see.
Sixty years ago they smiled
At lover, husband, first born child.
Smiles are for youth. For old age come
Death’s terror and delirium.4
Hospitals are significant places for people, places of birth and death. The interactions patients have with health care professionals within these places can be extraordinary and highly significant. Although this significance may, understandably, become lost on medical students through busy days on clinical placement, through reading literature there can be a reconnection with the patient perspective. This is shown in Larkin’s poem “The Building,” with the “place” being a hospital in Hull, United Kingdom4:
This place accepts. All know they are going to die.
Not yet, perhaps not here, but in the end,
And somewhere like this. That is what it means,
This clean sliced cliff; a struggle to transcend
The thought of dying, for unless its powers
Out build cathedrals nothing contravenes
The coming dark, though crowds each evening try
With wasteful, weak, propitiatory flowers.
Through offering renewed perspective and fresh insight literature can aid students in empathizing with the patient’s condition. In Allen Bennett’s A life like other people’s, he describes candidly his mother’s descent via depression to dementia and his interactions with the health care system in the United Kingdom.5 In this book we are given a son’s perspective on his mother’s illness and how this comes to affect the whole family.
His descriptions of the care home where his mother was placed, like Larkin’s poems, remind us of how alien and terrifying such places can be. In one particularly insightful account of his mother’s Alzheimer’s Bennett describes beautifully how the uniqueness of self within his mother is gradually lost as her disease progresses. He uses the metaphor of her changing appearance to illustrate this. Other people’s clothes and glasses gradually become her own due to the home’s chaotic laundry system, until she has none of her own clothes left. In addition the nurses stop using his mother’s correct name, instead using a nickname, over familiarity that he believes his mother would have found “common.” Reading passages such as this allows us to transport ourselves into the shoes of those who are going through difficulty and suffering. This can cultivate our empathy by revealing to us pertinent aspects of a patient’s illness that may be unrealized or unappreciated.
Descriptive accounts of actual illnesses in literature are also useful in increasing our understanding of patients’ perspectives and cultivating empathy.6 In psychiatric conditions this is particularly relevant as disorders can involve altered aspects of personhood that we may find hard to comprehend.2 Literature, especially written by authors who have experienced mental illness, allows us to engage within the minds of those who have suffered from psychiatric conditions. In Gilman’s short story “The Yellow Wallpaper”7 the narrator is suffering from an unspecified nervous aberration.7 In her own life Gilman suffered from depression, which she described as a “sort of grey fog drifting across my mind that grew and darkened,” leaving her a “mental wreck” with “constant dragging weariness, absolute incapacity, absolute misery.”7
In the short story the narrator is also a woman suffering from depression-like symptoms who gradually becomes obsessed with the yellow wallpaper in her room, where she is imprisoned by the well-intentioned orders of her husband, a physician. The short story brings us closer to understanding the feelings experienced during depression:
I don’t feel it is worth my while to turn my hand over for anything, and I’m getting dreadfully fretful and querulous. I cry at nothing, and cry most of the time. Of course I don’t when John is here, or anybody else but when I am alone. And I am alone a good deal just now.7
Students can read about symptoms such as these described in any list from any text book, but to understand how they may feel requires an act of imagination, one which is necessary to be a good doctor. Literature can aid us in this endeavour by connecting us to the deeper elements in a patient’s psyche, enabling us to view things more effectively from their perspective. The examples from Larkin, Bennett, and Gilman show how through imagining and engaging with literary characters presented to us health care professionals can see things from a fresh perspective and develop empathy.
A broader context
“The Yellow Wallpaper” is also useful in demonstrating how medical students must be aware that medicine is practiced within personal, cultural, and political contexts. The short story is a feminist work that is believed to have been written in response to Gilman’s own patronising treatment by an eminent nerve specialist of the time. In it she exposes the patriarchal and patronising practices of the narrator’s husband, a doctor. Referred to as a “little girl” the narrator is encouraged to avoid all contact and creativity.7 Her isolation and imprisonment in the room with the yellow wallpaper mirrors the restrictive and crippling social and economic pressures imposed on women in the nineteenth century. Eventually her sanity is lost and she begins to see hallucinations and delusions arising from the wallpaper. The short story reminds us that medicine is an important factor in, and a reflection of, our cultural and political landscape. Reading literature such as “The Yellow Wallpaper” can enable students to remain aware of and sensitive to this fact.
Aesthetics and narratives
The aesthetic approach to using literature in medicine is stated to create improved interpretational skills of narrative when interacting with patients.9 It suggests that the skills developed when thinking about characters in a novel can be applied to understanding patient narratives in the real world.2
In medical education we see narratives all around us. Conducting a patient history is essentially eliciting a narrative. When hearing this narrative back there is a need to use intuition and imagination to interpret aspects of what the patient has said. Certain literary devices are relevant in this regard. The unreliable narrator is one such example. In Ian McEwan’s Enduring Love the reader is unsure whether to trust the description of events by Joe, the narrator and protagonist.10 In the story, his wife begins to question his interpretations of events, sowing the seeds of doubt in the reader. Certain red herrings are placed in the plot such as Joe’s hand writing, which is remarkably similar to Jed’s, his stalker who is ill with de Clerambault’s syndrome. Understanding this unreliability in narration is an important skill that can obviously be related to clinical practice, such as when trying to extract information about socially unacceptable behaviors such as drinking to excess.
Another example of a literary device that could be relevant to clinical practice is multiple narrators. In Willkie Collin’s detective novel The Moon Stone, eleven different narrators describe the story of the stolen moonstone from their points of view.11 The book highlights the difference between subjective experience and objective reality; it requires the reader to interpret what each narrator is saying through an understanding of their viewpoint. In certain situations, such as emergency medicine, pediatrics, or geriatrics in particular, understanding this difference may be of clinical benefit.
Patients themselves often have their own personal narratives which drive their decisions and behavior. Reading can help us to encounter some of these narratives in literature. For example, some patients may be rebellious against hierarchy and authority, such as McMurphy in One Flew Over the Cuckoo’s Nest.8 Others may be neurotic and overly troubled such as Dostoyevsky’s narrator in Notes from the Underground, or his creation in The Double Mr Yakov Petrovich Golyakin,12 while others may be driven to understate their pain such as Allen Bennett’s father in A Life Like Other People’s.5 Understanding these personal narratives can help doctors predict the reactions and behavior of their patients and improve communication.
The degree to which the skills picked up when reading a novel can be transferred to real interactions is debatable. However, an understanding of narrative is unquestionably important in medicine. Although the aesthetic approach to understanding narrative may appear slightly academic to some, the general idea, that through reading literature medical students can better understand and communicate with a variety of people, is convincing.
Reflecting and connecting
Literature can give us a greater appreciation of the patient’s perspective, their stories, and their illnesses. However, to become good doctors, students also need methods of connecting with their own inner thoughts and feelings. It is often purported that in clinical practice one must maintain a level of detachment.13 However, to never let the guard down and feel is inhumane and harmful. In literature there is a safe place to allow feelings, inappropriate at the bedside, to be revisited and reflected upon. In Allen Bennett’s A Life like Other People’s he describes the quiet dignified life and death of his parents.5 After getting to know the characters of his parents and their relationships with Bennett, we are in need of his reflections upon their death and how he resolves this issue within himself. Through his insights on this subject students can reflect upon their own thoughts on life and death. Literature such as this can allow students and clinicians to relive feelings during periods of death and suffering that, at the time, were necessary to suppress; this can perhaps help them find some level of resolution and resolve.
Arguments that question the proposed benefits of literature
Despite some convincing arguments for the benefit of literature to medical students there are many who do not see a clear relationship between the arts and medical education and there are more still, due to their hectic schedules and demanding studies, who fail to find time to connect with literature even if they wish to.
Earlier in this essay it was discussed how reading may allow students to develop their empathy. However, the argument that the arts can increase our empathy for those in suffering and therefore make us more caring people is challenged by many.15 In A Clockwork Orange by Anthony Burgess, the main protagonist Alex, leader of the “droogs,” involves himself in acts of indiscriminate “ultra-violence” yet Burgess chooses to give his character a love of Beethoven.16 This juxtaposition of high art with inhumane acts illustrates how an appreciation of the humanities does not necessarily make someone humane.
It must be acknowledged that the content of what we read may not always instil within us empathy and a caring nature befitting of a doctor. For example in Ayn Rand’s novel Atlas Shrugged she presents through fiction the arguments for her philosophy of rational egoism and demonstrates her rejection of ethical altruism.17 This philosophy is largely incompatible with large sections of the Hippocratic Oath. This example goes to show how books in themselves are not necessarily “good” in the sense that they may not contain ideas that are suited to the practice of ethical medicine.
In a separate point there is a notion that overly ‘bookish people’ who substitute experience for literary representations in the process lose touch with reality.2 Marcel Proust acknowledged this when he wrote “reading is on the threshold of spiritual life; it can introduce us to it; it does not constitute it.”18 In medical education this statement will often hold true—literary descriptions of medical emergencies or the experience of seeing death will never be as powerful as experiencing them for real.
These arguments should not be dismissed offhand; many patients would be worried if they believed their doctors were spending too much time reading novels and not enough time reading text books. However, the arguments presented fail to recognise how art need not be a substitute for science or a crutch for the inexperienced and un-personable—it can become a part of life, giving color, insight and space to reflect.
This essay has explored the assertion that literature is of benefit to the medical student. Reading literature can enable us to see things from multiple perspectives and cultivate our empathy, allowing students to connect more deeply with the emotions of patients. Moreover, depictions of medicine in literature give us an artistic and culturally contextualised view of its practice, allowing students to reconnect with the wider context and significance of their field. Literature also provides a space for personal reflection and connection with emotions suppressed in day-to-day clinical education. There are arguments that question the proposed benefits of literature and many are disinclined to believe it beneficial. However, there are the beginnings of sea change in this point of view, and for students who are inclined to read literature, it can be a great comfort, an insightful teacher, and an invaluable tool.
- Keats J. John Keats letter to Benjamin Bailey. 1817.
- Oyebode F. Mind readings literature and psychiatry . London: The Royal College of Psychiatrists; 2009.
- Elliot T,S. Notes towards the definition of culture. London: Faber Faber; 1973.
- Larkin P. Collected poems. London: Faber Faber; 2003.
- Bennett A. A life like other people’s. London: Faber Faber; 2009.
- Charon R. Literature and medicine, contributions to clinical practice. Annals of Internal Medicine. 1995;122(8):599-606.
- Gilman Charlotte Perkins. The yellow wallpaper. London: Virago Press; 1981.
- Kesey K. One flew over the cuckoo’s nest. London: Penguin Classics; 2002.
- McLellan MF, Jones AH. Why literature and medicine? Lancet. 1996;348(9020):109-111.
- McEwan I. Enduring love. London: Jonathan cape; 1997.
- Collins W. The moon stone. London: Penguin; 1994.
- Dostoyevsky. Notes from the underground. London: Penguin Classics; 1972.
- Kirklin D, Richardson R. Medical humanities a practical introduction. London: Royal College of physicians; 2001.
- Barnes J. The sense of an ending. London: Random House; 2011.
- Bloom H. How to read and why. London: Fourth Estate; 2000.
- Burgess A. A Clockwork orange. London: Penguin; 2011.
- Rand A. Atlas shrugged. London: Penguin; 2007.
- de Button A. How Proust can save your life. Vintage; 1998.
MARTIN CONWILL is a fourth year medical student currently studying Psychological Medicine at the University of Birmingham (United Kingdom). He is hoping to graduate in 2015 and is looking forward to the challenge and responsibility of working as a junior doctor. He believes the humanities have a much wider role to play in medical education and can give prospective doctors a broader educational basis and a more open and rounded outlook toward their future practice.
Highlighted in Frontispiece Summer 2013 – Volume 5, Issue 3