Neurology, Arts and Humanities

It is not merely a matter of coincidence that the topic chosen by me today for 1st Dr. A.D. Sehgal oration is “Neurology, Arts and Humanities”. I vivid recall one of my first encounters with Dr. Sehgal in a Delhi Neuro-club meeting in 1983 in a small crampy room at his center where he hosted us warmly saying कमरा छोटा हो सकता है, पर दिल बडा होना चाहिये. He really had a big heart. I also remember that Dr. Sehgal presented a case of head injury with severe contusion in both temporal lobes of brain and went on to describe his abnormal behavior in great detail and then concluding its similarity with Kluver Bucy Syndrome. That was, in a sense, first encounter of a young aspiring neurologist with narration in medicine. Narration, story telling कथोपकथन, किस्सागोई.I wondered but did not fully realize then that, how well Dr. Sehgal portrayed the scene, despite being a surgeon.
I will be dwelling on this theme of narration or story today in relation to humanities.
It is again not a matter of coincidence that recently Medical Council of India has announced its intention to include humanities in curriculum of medical education. This thought has not come a day too soon. There is a great need for carving out space, and time and methods for inculcating humanities in medical education. This is also a great opportunity and a greater challenge for us.
Large number of colleges, universities and medical councils all over the world and even out IITs have already understood the need for and importance of humanities because they provide a wide angle lens perception of the human and social context of the illness and disease. Arts and humanities offer an opportunity to understand what makes us human, including vital features that cannot be titrated in a beaker or imaged with X-rays. Novelist Dorothy Alison has said- Fiction is a great lie that tells us the truth about how the rest of the world lives. The voice of a patient is often better and beautifully captured in fiction rather than case report.
What are humanities : The humanities are academic disciplines that study the human condition, using methods that are primarily analytical, critical, or speculative, as distinguished from the mainly empirical approaches of the natural science.
The main thrust of my presentation today will be on medical humanities – what are they, what is their context and scope, why do we need them, Can they be taught ? Can their teaching be worthwhile ? what are the methods ? What is evidence about their efficacy ? Do they really need an evidence ? Is it possible to generate evidence for an endeavor like this ? Who makes the syllabus ? Who teaches ? How much and when ? – and finally Neurology – How and why neurology, of all medical specialties – so much more closely related with arts and humanities.
I hope this meeting today will be part of a churning process, a catalytic event, a brain storming, a fodder for thought at MCI, outside MCI, so that this much delayed incorporation of humanities in medical education is realized soon and in an effective manner.
The humanities include ancient and modern languages, literature, law, history, philosophy, religion, and visual and performing arts such as music and theatre. The humanities regarded also as social sciences include technology, anthropology, area studies, communication studies, cultural studies, and linguistics.
The humanities are the stories, the ideas, and the words that help us make sense of our lives and our world. The humanities introduce us to people we have never met, places we have never visited, and ideas that may have never crossed our minds. By showing how others have lived and thought about life, the humanities help us decide what is important in our own lives and what we can do to make them better. By connecting us with other people, they point the way to answers about what is right or wrong, or what is true to our heritage and our history. The humanities help us address the challenges we face together in our families, our communities, and as a nation
Humanities should not be confused with Humanism, humanity or मानवता
Humanities are not a foreign body for medicine. The term “Medical Science” is a bit of misnomer. Medicine is basically a caring profession, an art, which also uses science, judiciously, for benefit of patients.
Edmund D. Pellegrino wrote that medicine has always been situated between science and technology on the one hand, and the needs of suffering human beings on the other. Medicine connects technical and moral questions in its clinical decisions: it is required to be both objective and compassionate. It sits between the sciences and the humanities being exclusively neither one nor the other but having some of the qualities of both.
Franklin had said that for thousands of years the physicians have worked with three things. The herb, the knife and Kind words.”
Let us look at this symbol –with the two serpents entwined on the staff, one Knowledge and one Wisdom. The legend said that the warring serpents were writhing on the ground but were pacified by Hermes who passed a staff between them, Knowledge and Wisdom aren't necessarily opponents, but they are opposites, and they must be reconciled and made supporters of each other. For the physician, Knowledge comes from without, and from education and study, enabling him to help patients. Wisdom, on the other hand, is an introverted element of the doctor's psyche, coming from within... and it is what makes him look not at the disease, but at the bearer of the disease. It is what creates the link that united the healer with his patient, and the exercise of which makes him a true physician, a true healer, a true child of Hermes. It is Wisdom that tells the physician how to make the patient a partner in his own cure. Instead of calling them Knowledge and Wisdom, let us call them Science and Humanism.
So I hope that everyone will agree with me that the medical humanities are not an oxymoron. Rather they are ‘natural allies’. Medicine and art have a common goal: to complete what nature cannot bring to a finish- to reach the ideal.. to heal creation. Literature and arts enrich language, experience and thought processes of physician, providing a wealth of concepts and ideas with which to think about health care.
Medical humanities should not be defined too narrowly as health care ethics or economics. Medical humanities should be a loose coalition of concerns, people, discipline, approaches and methods that are engaged in a fairly open ended dialogue.
Medical humanities add values to life at a number of different levels. It should not become exclusivist or elite or expert dominated. It should not be burdensome in its expectations and demands. It should not be imposed as an extra compulsory part of an already over crowed syllabus. It should be fun, amusing, interesting, entertraining as much as though provoking, exciting, and satisfying. Medical humanities should be more often elective rather than required.
We need medical humanities because the situation is bad.
Many medical reports, surveys and polls demonstrate that citizens are deeply distressed by the quality of their medical care. Frequent criticisms are – ‘physicians do not get to know me, not spending enough time with me, does not greet me by my name. What has happened to human qualities in medicine ? And then people vote by their feet. Many walk over to quakes or unproven, unscientific so called alternative medicine.
Traditionally there used to be three streams of carrier for students. Arts, science and commerce. Someone commented that medicine used to be art, then it became science, so far so good, but now it has become commerce. While economics of medical practice for a physician is a legitimate subject, I will not be commenting today upon good or bad of commerce in medical profession. I will restrict to art and science.
There are many contrasting, opposing or contradictory aspects of biomedical science on one hand and the caring humanities on the other.
Science resorts to a high level of abstraction to promote a theory and then test it. Science omits many aspects or facets of reality that cannot be accommodated in theory. Other things now become secondary, subjective or unreliable. These unimportant dimensions include all the patient’s experiences and reactions. We approach the patients as an object of interest rather than a sympathetic subject.
Science is also accused of reductionism, depersonalization and arrogance. Science is cold, unfeeling and sometimes dangerous while humanities are warm hearted and well intentioned but possibly less scientific.
Famous Physician Author: Dr. Abraham Vergese has this to say - The student may hear a patient say, “the pain started at four in the morning and it immediately reminded me of my father because he died of cancer and it began with a similar pain. I called my sister in Washington and she was worried too and she suggested I take a hot bath…” But what the student records in the chart is not the voice of the patient, but the voice of medicine, a formal language important for diagnosis and that sounds like this: “This 47-year-old white female developed the acute onset of left flank pain eight hours prior to admission…” This language is essential for diagnosis, but the danger is great that students may begin to think of their patients as simply the “diabetic foot in bed two,” the “myocardial infarction in bed three” or the “chronic renal failure in bed five.” Through the humanities — literature, art, theater, and film — we can keep the students’ imagination of the suffering of others alive.
जब एक किशोरवय युवक या युवती कडी प्रतिस्पर्धा में अपनी मेहनत और मेधा के बल पर मेडिकल कालेज में सपनों भरी आंखों से प्रवेश लेता है तब उसके मन में आदर्शवाद, मरीजों की सेवा की भावना और मानवीय संवेदनाओं की कधी उर्वर जमीन तैयार रहती है। फिर पता नहीं कब और कैसे, धीरे-धीरे वे मरीजों को दूसरा और खुद को अपने वरिष्ठ डाक्टर्स व अध्यापकों की श्रेणी में रखकर एक सीमा रेखा बनाने लगते हैं। डाक्टर्स जो स्वस्थ है, अजेय है, अधिकारी है, ज्ञानी है, कुशल है, सफल है, और मरीज ? जो असमान्य है, शिकायत करने वाले हैं, तकलीफों के पुलिन्दे हैं,असंतोषी हैं, अशुद्ध हैं, कर्मफल भोगने वाले हैं। यह निहायत ही महत्वपूर्ण है कि हम हमारी पहचान किस रूप में ढूंढते हैं। अपने गुरूजनों और सफल डाक्टर्स में खुद का बिम्ब या रोलमाडल तराशना एक हद तक ठीक है। परन्तु मुश्किल तब होती है जब एक युवा चिकित्सक यह भूल जाता है कि वह स्वयं या उसका कोई परिजन भी मरीज हो सकता है और यह भी कि चिकित्सक का खुद का ज्ञान और उसके शास्त्र की सीमाएं हैं या यह कि मरीज की देखभाल ठीक से करने के उसके प्राथमिक कर्त्तव्य के लिये न केवल वैज्ञानिक ज्ञान बल्कि इन्सानों के रूप में मरीज, घरवाले और स्वयं डाक्टर का व्यक्तित्व, चरित्र, भावनाएं, संवेदनाएं, मूल्य, इच्छाएं, महत्वाकांक्षाएं, उम्मीदें, भय, शंकाएं आदि के जटिल संसार की समझ होना है चाहिये।
एनातोल ब्रोयार्ड न्यूयार्क टाइम्स के पुस्तक समीक्षा विभाग के प्रमुख सम्पादक थे तथा साहित्यिक आलोचक के रूप में प्रतिष्ठित व ख्याति प्राप्त थे। १९९० में प्रोस्टेट केंसर से उनकी मृत्यु हुई। बीमार होने के बाद उन्होंने रोग और मृत्यु विषय पर निबंधों की एक श्रंखला लिखी जो मरणोपरांत मेरी बीमारी के नशे से ग्रस्तङ्ख शीर्षक से प्रकाशित हुई। एक खास निबंध मरीज करे डाक्टर की जांचङ्ख दोनों के आपसी सम्बन्धों पर पैने सवाल उठाता है। ब्रोयार्ड अपनी बीमारी के लक्षणों के बारे में बताते हैं । उन्हें पेशाब करने में रुकावट होती है। यूरोसर्जन से उनकी मुलाकात व बातचीत को मजेदार तरीके से बयान करते हैं। उनके अनुसार डाक्टर कैसा होना चाहिये-जो बीमारी को बारीकि से पढे, चिकित्सा का अच्छा समालोचक हो.... जो कि शरीर और मन (दोनों) का इलाज करे.. मैं चाहुंगा कि मेरा डाक्टर मेरा पूरा मुआयना करे.. मेरी प्रोस्ट्रेट ग्रंथि के साथ-साथ मेरी रूह को भी टटोले। ऐसा डाक्टर जो गम्भीर रूप से बीमार व्यक्ति के एकाकीपन की कल्पना कर सके और महसूस कर सके कि मैं क्या अनुभव कर रहा हूँ। जो जानता हो कि प्रत्येक मरीज को बचाया नहीं जा सकता परन्तु रोग की पीडा और दुःख को कम किया जा सकता है - इस बात से कि डाक्टर का व्यवहार कैसा है - और अन्ततः डाक्टर अपने आप को बचा पाता है। एक अस्पताल, प्रयोगशाला के बजाय थिएटर (कलाक्षेत्र) जैसा अधिक होना चाहिये। Clinical detachment needs to be balanced with emotional engagement. The emotional burden of keeping a professional distance is much harder on the doctor than be imagines.
All this does not mean denigrating science. I am a great fan, supporter and believer of science. I would never take side with John Keats when he accused Newton of taking away the joy of watching a rainbow by explaining “away’ its physics.
Modern medicine has done good for society by conceiving disease in terms of pathophysiological mechanisms and thus replacing ideas like punishment from God or signs of moral weakness or ‘karma’ . Yet somewhere there is some loss. There runs a risk of reducing the patient to a disease or an object ; a practice that enhances controllability and safety but reduces empathy.
Technical knowledge and skills can be acquired through training with little reflective process, it is impossible to refine attitudes, acquire virtues, and incorporate values without reflection. The point here is how to provoke students’ reflective process. Learning through aesthetics—in which cinema is included—stimulates a reflective attitude in the learner. The first step in humanizing medical education is to keep in mind that students are reflective beings, and they need an environment that supports and encourages this activity. Because emotions and images are privileged in popular culture, they should be the front door in students’ learning process. When systematically incorporated into the educational process, and allowed to flow freely in the educational setting, emotions make learning both more memorable and more pleasurable for students
In medical science human beings are portrayed as stick figure character with predictable responses – all or none, black or white, this or that – hence what do we get? thinned out case reports, algorithms, practice guidelines which are superficial, homogensed and too reduced to be real. In literature and arts, human nature and person hood is conceived as chaotically complex. The self and emotions are divided. The values are hidden and conflicted. There are layers of uncertainly at multiple levels – the consultant, the residents, the patients, and the caregiver. Modern case histories allude to subjects in a cursory phrase: a trisonic albino female of 11. A rat or a human being ? There is need to deepen case history to a narrative or a tale. The power to describe richly human clinical tales which was so common in 19th century is almost gone. Ever read the descriptions by James Parkinson or Charcot? Rita Charon at New York has evolved concepts and methods like ‘Narrative evidence based Medicine’ and ‘Parallel charts’. Each patient has a unique story. Doctor is a part of the story. Both influence each other. One needs to walk an extra mile in shoes of other to develop empathy.
Here I would like to share some of my readings related to medical humanities, अंतस के परिजन (भवान महाजन) ), V.S. Ramchandran, Jerome Gropman, Atul Gawande, Bellevue Literary review, David Watts, AR. Luria, Daniella Offin, My favorite author is Dr. Oliver Sacks
We had a great fortune and privilege to have 2 hours of tea time with famous author Neurologist Dr. Oliver Sacks at his residence in New York. He has revived the art of clinical tales.
He says “I am a physician first. This morning I saw a patient. It is true that I have had written a story about him. But when I see him, he is a not subject for me, but always a patient. I had a scientific impulse to write - initially in the form of article in journals and case histories. There was initially some conflict in my brain about two distinct instincts, which were located in different parts. Gradually they came together”
“My mother and father both were clinicians but in a way they too were storytellers. Story telling is an essential part of medicine. It helps you understand the physiology of a person.”
“One of the reasons why I like to tell stories and I like to get stories, is that these are stories of identity and impact upon it of neurological mishap. One such story I wrote was to see and not see; a story about the blind man, who has such a comfortable identity as a blind man, which is destroyed by restoration of vision.”
“I think there was a danger about twenty years ago that individual studies or studies of individual would get lost in statistics and lost in getting averaged out. My real teacher, though I never met him but only had correspondence was Luria and specially his two great studies in neurology of identity. The protagonist in the man with shattered world preserves his identity despite profound cognitive deficit.”
“I do not know what is meant by evidence-based medicine. Even case histories are evidence. What could be the alternative? Will it be faith based medicine or homeopathy. There are different sorts of evidence. Even a single case, which has been deeply studied for many years.”
“I am delighted by the complexities of case histories –It refers to richness and thickness of reality. I think our existing case histories are much too thin. A description of a Parkinsonism patient getting up and moving across a room, would need 30 or 40 pages of dense writing. It is in this way that a novelist and clinician will come together.”
Oliver sacks also emphazises history of medicine and quotes Cannizaro “the mind of a person who is learning a new science has to pass through all the phrases which science itself has exhibited in its historical evolution.” “It applied to me, I had a wonderful growing and living the history in myself. The notion may not be a agreeable to many. Evolution, growth and development of any subject is like a living organism. It has great pedagogical significance. I am neurology I constantly practice it.”
Oliver sacks also quoted to us Gerald Edelman noble laureate, in neuroscience whose central contribution had to do with scientific understanding of basis of human identity in neurological terms. Edelman said ‘What am I doing here. Shakespere said it all’.
एक छात्र ने थामस सिडेन्हम (कोरिया बीमारी का वर्णन करने वाले) से पूछा कि डाक्टर्स की प्रेक्टिस के लिये तैयारी में मैं कौनसी पुस्तक पढूं ? बिना झिझक के सिडेन्हम ने कहा डॉन क्विक्जोट पढो। बहुत अच्छी किताब है । १७ शताब्दी के बाद अब हालात बहुत बदल चुके हैं लेकिन उपरोक्त जैसी सलाहें और भी ज्यादा जरूरी हो गई हैं। जिन्दगी को अर्थ प्रदान करने वाले सपनें के बारे में और मृत्यु तथा दुःखों के झंझावतों को सहने का ज्ञान भला साहित्य के अलावा और कहाँ से मिलेगा ?
मानविकी और कलाओं में कहानियाँ हैं, विचार हैं, शब्द हैं जो जीवन और दुनिया को अर्थवक्ता और सार्थकता प्रदान करते हैं। साहित्य हमें ऐसे लोगों से मुलाकात करवाता है जिनसे हम कभी नहीं मिले, या जहाँ हम कभी नहीं गये या जो बात कभी हमारे दिमाग में कौंधी ही नहीं। दूसरे लोगों ने जिन्दगी को कैसे जिया और उसके बारे में कैसे सोचा यह जानने से हमें फैसला करने में मदद मिलती है कि हमारी अपनी जिन्दगी में क्या महत्वपूर्ण है तथा हम उसे बेहतर बन सकते हैं।
यहाँ मैं हाउसकाल्स का उल्लेख करूंगा। पहले डाक्टर मरीज के घर उसे देखने जाता था। यह अब कम होता जा रहा है। घर पर हम न केवल मरीज बल्कि उसका वातावरण, परिवेश, परिवार, माहौल - बहुत कुछ देख पाते हैं। वह कला, वह विा लुप्त हो रही है। डॉ. ओलिवर सॉक्स ने एक किस्सा सुनाया। उनके डाक्टर पिता जब बहुत वृद्ध हो गये तो परिजनों ने कहा कि अब काम कम करो। ऐसा करें कि हाउस काल्स बंद कर दें। वरिष्ठ डॉ. सॉक्स ने कहा - मैं अपना दवाखाना बंद कर देता हूँ पर हाउस काल्स जारी रखूंगा। डॉ. ओलिवर ने मरीज कथाओं के माध्यम से हमें ढेर सारी हाउसकाल्स करवाई हैं।
In this reference Housecalls magazine needs to mentioned and appreciated and recommended as part of reading in medical humanities. Though published by a pharma company, it is not about sales promotion and nor about medical sciences. It serves the goal of medical humanities most efficiently – Education for a moral sensibility of critical self reflection in care giving. Self reflection about our own hidden and divided values and those of our patients and their families.
It is this sensibility that animates and is animated by the everyday practice of care giving and it is this sensibility that makes the rest of the life, well, more livable. Humanities are not to educate students to become social scientists or ethicists or literate but instead to cultivate and develop a richer and receptive sensibility which is critically and aesthetically alert and morally responsive.
ग्रीक मायथोलाजी में जानुस नामक चरित्र है। दुः महा आगे और पीछे दोनों ओर देख सकता है। यह प्रतीक है द्वंद का , दुविधा का, व्यक्तित्व में फाड का । चिकित्सक का एक चेहरा वह जो प्रोफेशनल है। दूसरा वह जो उसका खुद का है। विभिन्न सभ्यताओं में इसी विरोधाभास का हल ढूंढने की युक्तियाँ निकाली गई थी। पुराने यूनान में कहते थे Paidea - सांस्कृतिक व शैक्षणिक रूप से समृद्ध व्यक्ति का आदर्श। पुराने चीन में कन्फ्यूशियस की शिक्षाओं में जोर था आन्तरिक मूल्यों के संवर्धन पर । अपने यहाँ महाभारत में धर्म और कर्त्तव्य की अवधारणा गढी गई।
David Sackett’s is a guru of Evidence Based Medicine. He says in preface that evidence based medicine is integration of (1) Best Research evidence (2) clinical expertise and (3) patients values which means – ‘Unique preference, concerns, expectations, each patients brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patients.
The whole edifice of medical education has been built to train for clinical expertise. In last two decades, some attention has been paid, with some good success in teaching how to appraise the literature and look for best research evidence. But what about patient values ? They are taken for granted. It is assumed that students have inherent or a priori knowledge or that they will learn on their own as a by-product or corollary of clinical work.
In New England journal of Medicine, dated 31st March 2011 there is a perspective article ‘Into the water – The clinical clerkship by Katherine Treadway and Neal Chaterjee’. The young Neal describes how during early clinical years the peer pressure and professional socialization through their jokes, slang, stories and language numb the sensibility of residents. They distance themselves from their own feelings and from their patient’s through intellectual engrossment in the biomedical challenges of diagnosis and treatment and through participation in highly structured, in group forms of medical humor. There is no guidance or mentoring about human aspects of caring.
It is a wrong question to ask ‘can you teach students to care? All of them enter medical school caring deeply and we actually teach them not to care, not intentionally but by neglect and silence.
There are many examples of teaching various aspects of humanities in colleges all over the world. The General Medical Council of Britain recommends special study modules (SSM) which are blocks of study set aside from the rest of the course to allow the students to study in depth areas of particular interest to them.
P.R. Shankar and team at KISTmedical college Lalitpur Nepal has been doing good work for 4 years. The name of their module is sparshnam. They found that small group discussions and role plays help.
Vijay Answani in West Indies uses literature in his biochemistry classes following the examination – like – Robert Frosts’ Stopping by woods on a Snowy evening or ‘The road not taken’ and Kabir’s – पोथी पढ पढ जग मुआ पंडित भया न कोय। ढाई आखर प्रेम का पढे जो पंडित होय and John Donne’s meditations. James Brawer at Monteral Canada uses philosophical perspective in teaching basic medical sciences. Reilly and colleagues at Los Angeles are trying to enhance visual thinking strategies through discussion on paintings. Dr. TJ Murray professor of neurology and Humanities at Dalhausie Canada has a very active programme with summer research studentships, humanities evenings at faculty club, discussion groups, brown bag lunch presentations, reading weak ends, public lecture, visiting professors and students presentations
Small group discussions have been used following movie clips and movie stills, either as stand alone or while inserted in the texture of a presentation.
Music has been used as a metaphor for communication in medicine with the hope that the art of listening and appreciation will have cross over effect while engaging with patient stories. Reading clubs are a common activity where students and faculty share their readings and discuss the implications.
According to Rita Charon : The work of medicine depends on the physician’s ability to listen on the stories patients tell, to make sense of their often chaotic accounts of illness to inspect and evaluate the listener’s personal response to the story being told, to understand what these narratives mean.. and to be moved by them.
The use of the humanities and arts in medical education has also grown in the last 40 years, to the extent that over half to three-quarters of all U.S. and Canadian medical schools (depending on one’s definition) have some sort of curricular offering in the medical humanities. The purposes and goals of such endeavors are various, but include a desire to educate medical students and residents more broadly about the human condition; help them to understand different points of view and thus to develop clinical empathy; stimulate reflection and critical thinking; better tolerate ambiguity and uncertainty; and reconnect them with aspects of awe and mystery in the practice of medicine.
The content of such coursework is variable, but can address historical topics, such as gender and race in the profession of medicine; the doctor-patient relationship; the patient’s experience of illness; and issues such as death and dying, difficult patient-physician interactions, breaking bad news, cross-cultural medicine, and similar topics that are difficult to fully apprehend from purely didactic instruction.
Looking over this diverse and thought-provoking collection of work, three broad conclusions emerge. The first is the power of the humanities to engender reflection in learners by incorporating radically different perspectives from those normally represented in medicine for apprehending and interpreting the world. The second is that the concept that clinical medicine is performative contains exciting, and by and large still unexplored implications, for the profession. Third is the realization, or at least the possibility, that clinical medicine is a profoundly cross-disciplinary experience; and that in preparing students for their future roles as physicians, it behooves us to draw on many fields of knowledge, not only the basic sciences and clinical medicine, but also the arts and humanities