In Sickness and In Health : The Sharing of Pain in Namibia

Between a doctor and a patient, there is a very special and unique relationship contained in an exclusive realm. The connection is formed from the presenting of an illness and the sick are drawn to the healing. The healer in turn aspires to release the sick from their symptoms and pain. Our wonder of medicine sometimes overlooks the elements that symbolize the very nature of our human condition of this shared relationship – recognition, empathy, compassion of the Other. One example of the act of healing from Namibia however reveals the true essence of the human to human connection and the role of medicine in how we experience our world.
In the desert, distances away from the familiarities of the West, two women sit opposite each other on the bare earth. One of the women, an elder, is experiencing acute pain. She can locate the pain to her heart but the pain is all encompassing. It conducts through the whole of her body and smashes through one cell to another, carrying destruction to reach all of her being. The energy from the pain, its heat and the awareness of the body’s aliveness, transpires into a particular state. In this state, the woman focuses on expelling the pain that she believes is a curse.
The pain’s momentum is experienced as the speed of a spirit that has possessed her body. The body and the spirit are two separate entities that on this occasion have become entangled in her life force. The woman is not powerful enough to kill the curse. She can only direct it towards the woman, a healer, sitting opposite her.
The pain, or curse, is propelled from the body and it is invited to be absorbed into the body of the healer. The healer becomes possessed by the curse, and the elder woman is born back into life. The healer labors through the curse. The curse has entered her body but her powers of healing prevent it from identifying with her physicality. In a heightened trance the curse is combated. Slowly the healer begins to relax and the curse is dissipated.
As the cultural relativists would describe, a culture is a natural entity of which individuals are part of. The medicinal world that the woman elder and the healer belong to are as real and ingrained in experience as our hospital setting is in our experience. Yet, the narratives of each show a common illumination of our human discrepancy. Through embarking in a relationship of kindness – perhaps adopting the words of Hippocrates of “doing no harm” – medicine is the ultimate tenderness of care other than when a mother gives life to her child.
Whilst we in the West prescribe a third party into our medical relationships, namely that of chemical (pills)  or physicist (radiotherapy/ imaging) or biological (transplants) to embody the pain that illness curses, we still embark on a journey to remain with life.
The presence of pain, ironically, enables one to develop the skills to reach and help another person.
And , pain can strike in the deserts, on islands in the wide oceans, within the majesty of mountains or in the hospitals that are sterile and armed with technological apparatus to battle any invasion of suffering.
So, I believe that the lesson to carry in our minds, and let fly in our perspective is that of remembering that no matter how deep our knowledge may travel in the researcher’s laboratory, or the doctor’s clinical room, the essence of medicine is in the joining of one person’s experience to another.
How that experience is conveyed – whether through ritual or narrative or diagnostic charting – is only ever a symptom of what belies the curse of illness – namely, the gift of the relationship between the sick and the healing.

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’21st Century Medicine, Aristotle And The Church’ by Dr. Andrew R. J. Tillyard

I recently attended the funeral of the local parish priest and this led me to consider many of the similarities between what I do in medicine and the role of the ‘Parish Priest’ as well as the ‘misrepresentation’ of 21^st medicine. I work in intensive care, a setting of immense emotional stress for patients and relatives, and not infrequently for staff as well. Intensive care can appear more like the cockpit of an aeroplane – full of machines that bleep and flash as they keep patients alive. This, however, can belie the true meaning of what we do. There is an evolving mis-interpretation of what medicine is: that good medicine in the 21^st century is skill based technical wizardry, where ‘good’ doctors are people, who can diagnose, treat and cure using magnetic resonance imaging (MRI’s), gene therapy, or laser guided scalpels and the like.
I believe that what a patient wants first and foremost is a physician who is compassionate, honest and committed to their cause. Without these under-pinning attributes, their drive to find the best treatment for each of their patients will be diminished. William Osler said in 1907 that “You (physicians) are in this profession as a calling, not as a business, as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone”.[1] And for ‘business level’ one could insert ‘disease or diagnosis’. The patient is just one part of the whole person just as the successful treatment is just one part of an illness journey (al-be-it a vital part). Knowing the physician is compassionate, committed and honest forms the foundation upon which the scientific wizardry starts to work. It also has a very real beneficial treatment effect (placebo). And this is where Aristotle returns to the fray of modern medicine.
Aristotle’s  Nichomachean  Ethics sets out the three stages of virtue ethics: arête (knowledge), phronesis (practical wisdom) and eudaimonia (flourishing – performing as an expert).[2] Part of knowledge is an understanding of what personal attributes (dispositions such-as compassion, humility, justice and courage which Aristotle called ‘virtues’) are required to ‘flourish’. As doctors (and I assume clergy) become more knowledgeable and experienced, the good virtues (dispositions) that make them strive to do the best for patients becomes in-grained in how one performs as a physician. Put generally, we professionals, sailors, gardeners, mothers, etc have a duty to do what we do with good intentions. And the more we do this, the better our abilities will be. Comte-Sponville has said that to flourish is an individual’s accountable task; virtue and especially that of compassion are pre-requisites and to be without them is to be ‘inhumane.’ [3] Virtue is ‘a force that has or can have an effect’: it gives the person their distinctive excellence. It is this acting well that makes a person ‘more humane’.  In Immanuel Kant’s terms, it is one of the individuals duty’s to others. [4]
An Aristotilean ‘good doctor’ or ‘good priest’ will not always make a good decision. Indeed, there is a circular argument here: it could be considered morally presumptuous to assume a consultant physician is a virtuous, or good doctor just on the basis of training or level of seniority, and therefore will always make good decisions. But, this in-part misses the point. It is the underlying virtues of a doctor that will make them reflect and study, coupled with experience and a desire to determine what is in the patients best interests, that will lead to good decisions. Put more simply, it is the underlying virtue to help that is necessary to start being of help.
As our lives become ever more technological (internet, texting and tweeting), there is a risk to three necessary elements of living well: communication, listening and understanding. There is a cliché – time heals all wounds, but I would argue based on my experience with patients and their loved ones that, providing them with understanding and a chance to voice their views, will heal those wounds more quickly. Thankfully, as technological advances allow us to preserve the heart beat of patients ever longer, the Department of Health is also starting to recognise the importance of understanding the person as a whole, as evidenced by the drive to allow patients to say what they would ideally like or not like when they come to the end of their lives (the “Preferred Priorities of Care” and “Advance Decisions” (living wills) documents that people can complete). This is first and foremost though, a role of family, friends and professionals.
References
1: Osler W. The reserves of life. St Marys Hospital Gazette. 1907; 13:95-8
2: The ethics of Aristotle: the Nichomachean ethics. (translated JAK Thompson, revised Hugh Tredennick). London, Penguin Books, 1976
3: Compte-Sponville A. A short treatise on the great virtues. London: Vintage, 2003
4: Ameriks K. ‘Immanuel Kant’ in The Cambridge Dictionary of Philosophy. Ed. R. Audi. Cambridge: Cambridge University Press 1999
Dr. Andrew R. J. Tillyard
Clinical Academic Lead for Medical Ethics and Law, Peninsula Medical School
Consultant in Intensive Care Medicine, Derriford Hospital
andrew.tillyard@pms.ac.uk

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‘Comics & Medicine: The Sequential Art of Illness’: Conference, Chicago, 9-11 June 2011

This second international interdisciplinary conference* aims explore the past, present, and possible future of comics in the context of the healthcare experience.  Programs in medical humanities have long touted the benefits of reading literature and studying visual art in the medical setting, but the use of comics in healthcare practice and education is relatively new.  The melding of text and image has much to offer all members of the healthcare team, including patients and families.  As such, a subgenre of graphic narrative known as graphic medicine is emerging as a field of interest to both scholars and creators of comics.
We are pleased to confirm two important keynote speakers: David Small, author of ‘Stitches’ and Phoebe Gloeckner, author of ‘A Child’s Life’
We invite proposals for scholarly papers (15 minutes), poster presentations, and panel discussions (60 minutes), focused on medicine and comics in any form (e.g., graphic novels, comic strips, graphic pathographies, manga, and/or web comics) on the following—and related—topics:

• graphic pathographies of illness and disability
• the use of comics in medical education
• the use of comics in patient care
• the interface of graphic medicine and other visual arts in popular
• culture
• ethical implications for using comics to educate the public
• ethical implications of patient representation in comics by
• healthcare providers
• trends in international use of comics in healthcare settings
• the role of comics in provider/patient communication
• comics as a virtual support group for patients and caregivers
• the use of comics in bioethics discussions and education

We also welcome workshops (120 minutes) by creators of comics on the process, rationale, methods, and general theories behind the use of comics to explore medical themes. These are intended to be “hands-on” interactive workshops for participants who wish to obtain particular skills with regard to the creation or teaching about comics in the medical context.
We envision this gathering as a collaboration among humanities scholars, comics scholars, comics creators, healthcare professionals, and comics enthusiasts.
300 word proposals should be submitted by Friday, 28 February 2011 to submissions@graphicmedicine.org. Proposals may be in Word, WordPerfect, or RTF formats with the following information and in this order: author(s), affiliation, email address, title of abstract, body of abstract.  Please identify your presentation preference: 1) oral presentation; 2) poster presentation; 3) panel discussion; or 4) workshop. While we cannot guarantee that presenters will receive their first choice, we will attempt to honor people’s preferences, and will acknowledge the receipt of all proposals submitted. Abstracts will be peer-reviewed by an interdisciplinary selection committee. Notification of acceptance or rejection will be completed by 14 March 2011.
This event is co-sponsored by the Medical Humanities and Bioethics Program at Northwestern University Feinberg School of Medicine, the Department of Humanities at Penn State College of Medicine, and the Science, Technology and Society Program of Penn State University, and is supported by a grant from the Charles Schulz Foundation.
*Information about the 2010 conference, “Comics and Medicine: Medical
Narrative in Graphic Novels,” in London, England can be found at
www.graphicmedicine.org.
Dr Ian Williams

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The Genie in the Syringe

Throughout the Christmas season, pantomime performances are one of the UK’s most favoured traditions. The pantomime has a long history with a genesis in Ancient Greek times. In our modern era, pantomimes are often adapted to feature contemporary twists and understandings about the unique and special meanings which have structured certain folk tales with a strength to survive the centuries.
In parallel, modern medicine has its roots in Ancient Greece and has seen many transitions and contemporary adaptations in the knowledge we possess about the human body.
Separated by worlds of fantasy and of reality, I have been struck by how the fables of pantomimes and the facts of medicine collide much closely than one would initially imagine.
“Aladdin” and “Ali Baba and the Forty Thieves” are some of the most famous tales taken from the “Book of One Thousand and One Arabian Nights”. Both of these are underpinned by the magic of transformation. The human body is suddenly enabled to perform the impossible and change the fate of our earthly physical determinants. Magic is also used in reverse to cast illnesses.
In Arabic folklore, the powers of changing fate and the body are called “djinn”, or the infamous “genie” in “Aladdin”. These are narratives reflecting some of the basic teachings in Islamic philosophy about our human condition. Djinns or genies, humans and angels are the three sentient creations of Allah. Like humans, djinns can be good or evil. In medicine, health is good and disease is the invasion of evil djinns.
The divide between creation and destruction, fate and transformation and good and evil is a common theme structuring the opposing worlds of fantasy and reality, pantomime and medicine. Modern medicine, however, does make me wonder. If medicine was not real, what would it be?
Another famous pantomime story is “Sleeping Beauty”, originating from the 16^th century. During this story, a princess is felled to sleep for hundreds of years and then awakened with the touch of another human being. Is this so different to modern medical metaphors? It is a practice in intensive care units to induce a coma and then to return consciousness to a patient.
Medicine is writing its own pantomime with fantasy of restoring life to a person through transforming the sick to the healthy.
There are many interventions akin to Aladdin’s lamp, hence the title of this blog “The Genie in the Syringe”. We insert substances, produce images from radio and sonar waves, manipulate the causal relationship between molecular processes to produce a transformation and create our own audiences in the operating theatre to the inner secrets of the body’s anatomy.
Medicine is a central character in our personal narration, sometimes featuring as a tragedy and at other times, as a miracle. As the meanings of folktales have changed over the centuries and changed from representing an integral part of life to forming entertainment, I wonder how the meaning of medicine will be perceived in future years. Medicine is already showing us performances between the doctor and patient that would have been beyond the imagination of the writers of “Aladdin” or “Sleeping Beauty” in the same way as their relevance exists in a different domain to the place from where it was written.
Thus, as the fantasy and reality of medicine grows in an evermore interweaved nature, it will be increasingly important to ground the roots of medicine’s own narrative in the stories that have stemmed from our curiosity and wonder about our own existence; how much we can change and how much is subject to an inevitable fate is the rule guiding the possible versus the impossible in medicine’s fight between good and evil, health and disease.

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Stories of the Land

Having recently visited some of the most modern hospitals in the world, I have been struck by the style of their architecture. There seems to be a changing face of medicine, whereby the expressions of the building housing the body of medicine mirror certain conceptualizations of the human body. I began to wonder how does this affect our experience of ourselves in both health and illness. From the compartmentalized, sterile structures of cosmopolitan cities to the shacks of mountainside shamans, what are the similiarities and differences to be found?

I have visited hospitals all over the world. I have seen the breeze block clinics hidden in the folds of the mountains of Lesotho, where the Basotho people shield Nature’s elements with huge blankets, cast around themselves like huge wings, too burdened with life to be able to fly.
I stood in the shadows of Pristina’s hospital, of a saddening grey exteriority, central to the country of Kosovo, from where its windows bore witness to the visitor of war haunting its walls, and burrowing into the ground holding its foundational pledge to heal and not to harm.
Then, I move to the neat boundaries of the United States of America and the towering glass buildings, ever so fragile yet not too afraid to expose and make transparent the anti-synthesis of health in this shining landmark. Inside the body remains within the same boundaries that map the grids of the city streets except it is not the way home that we are directed to but the different specializations evolved from years of intensive studying of the human body, that somehow finds the heart of Another in every room.
Following the sun set, I move to the South African plains, where fires and folk tales used to form the horizon swallowed up by an exodus to the cities, moving and forgetting the footprints of the Ancestors. In the air where communication would rise to those beyond a human freedom, the vast is open but empty. Its mind has wandered to a different pasture, into a nature we have created for a new way of being.
A transcending of physicality not quite sure where to go.
And I wonder for the movement of illnesses’ home in all of the travelling lands.
Where does the body of our Being become to belong to?
Hospitals are places where many people dread to enter, and contain the most important facets of our human condition; life, death, dying, and birth. It is therefore entirely understandable that the body, the identification of the person before us, and their experiences and memories are all represented within the structure of a hospital.
Our mind is the architect of illnesses design and hand in hand with Medicine itself, the corridors we walk through are ones constructed of hope, and perhaps, faith, and all lead to the envisioning of a cure, regardless of the material that the hospital is composed from.

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“Newspeak (PART TWO): British Art Now is doubleplusgood!” by Dr Jane R Moore

A few weeks ago I visited the new exhibition at the Saatchi Gallery with my group of 4^th year King’s College Medical Students. Visits to galleries, museums and art installations are an integral part of the ‘The Good Doctor’ Special Study Module but I hadn’t included the Saatchi Gallery before.  Modern conceptual art is challenging and I was uncertain how this visit would help in our exploration of medical matters. I need not have worried; our visit was enjoyable, reassuringly accessible and it was easy to make links to the theme of goodness in contemporary medical practice.
Newspeak Two on display in the large bright rooms at the Saatchi Gallery, King’s Road, London continues the showcase of contemporary British Art started in June 2010 with Newspeak One.  All the original exhibits, including the widely advertised Pink Cher by Scott King, have been replaced and the new collection opened at the end of October.  Charles Saatchi’s Sensation! exhibition (Royal Academy 1997) had – sensationally -  brought late 20th century British Art to public notice. This was the outing of Damian Hirst’s shark, Tracey Emin’s unmade bed, Mark Quinn’s blood sculptures, Chris Ofili’s ingenious uses of elephant dung and the Chapman Brothers doing what they do best – shocking us into a reaction.  So what would we make of Newspeak?
George Orwell coined the term newspeak in his dystopian classic Nineteen Eighty-Four[i].  This was the deliberately duplicitous politicians’  language which removed all shades of meaning from words.  For example, “think” used as both noun and verb makes the word thought superfluous so it can be abolished;  if pleasure / pain becomes  ”goodthink” any negative connotations can be dismissed.  In this way the total dominance of the State was reinforced leaving the population passive and malleable.  By calling this collection Newspeak is Saatchi mocking contemporary art?  Or is he referring to present-day “artspeak”, an artificial, pretentious, hollow and at times unintelligible discourse?  For our group this was our first link to contemporary medicine as we considered the role of  “medicspeak”.
Our guide, a postgrad art student, showed us some of her favourite pieces and gave brief descriptions.    We appreciated this guidance which allowed us to move on to our own interpretations and make links to contemporary medicine and society. On our own I think we would have been at a bit of a loss. Though a description of all we saw would not be practical here are some highlights.
Gallery 3 contained three massive, detailed and beautifully painted canvasses of men and machines by Jonathan Wateridge.  We liked Space Program 2008, a group of men posed in front of a spaceship under construction.  However on close scrutiny you could see the spaceship was a milk bottle, the launch control panel a mobile phone key pad, and the astronauts ‘spacesuits’ ordinary workmen’s overalls decorated with bits of household tat. Yet the men, in reality the artist’s friends, give the appearance of authority and confidence. We were reminded of Luke Fildes’ iconic picture The Doctor (1887).  This picture, painted at a time of increasing mistrust in the science of medicine, managed to suggest that medicine and the establishment as a whole, had the power to confront the difficulties encountered by society[ii].  In the same way we are lead to think that Wateridge’s unlikely astronauts’ competence and skill will surely lead to a successful expedition to further man’s mastery of outer space and so all is well with the modern world.
http://www.saatchi-gallery.co.uk/artists/artpages/jonathan_wateridge_space_group.htm
Anne Hardy (Gallery 5) has a series of four photomontages of ‘depopulated rooms that suggest surreal fictions’ according to the exhibition catalogue[iii]. What we saw were detailed photographs of the same space, some frames showing a clutter of carefully arranged seemingly miscellaneous objects:
http://www.saatchi-gallery.co.uk/artists/artpages/anne_hardy_cell.htm
Other frames showed an empty space with the outside crowding in;
http://www.saatchi-gallery.co.uk/artists/artpages/anne_hardy_drift.htm
We found these images claustrophobic but compelling; reminding us of both the workings of the human body with tortuous nerves and blood vessels, and of the machinery of modern medicine which cuts us off from normal communication with our patients.
In Gallery 10 The Followers, Ximena Garrido-Lecca has produced a huge reproduction of a Peruvian burial wall. Each niche containing photos, mementoes, plates of food or a bottle of beer by which the deceased were remembered by their grieving ‘followers’.  This is a beautiful exhibit, but after a short time as observers we became uncomfortable; we felt that we were intruding or showing a prurient misplaced interest in intimate details of people who had had no choice in the display and what it revealed. It was easy to make parallels to the role of the medical practitioner and our patients’ narratives.
http://www.saatchi-gallery.co.uk/artists/artpages/ximena_garrido_followers5.htm
So how do I justify this visit to the Saatchi Gallery to look at contemporary British art?  How can such activity be a valid and relevant and relevant contribution to undergraduate medical education?
Artists observe, capture and record visual images; when patients describe events, feeling, concerns, they set scenes using their own imagery; in turn, doctors listening to patients’ stories and descriptions form pictures in their own minds.  Looking at paintings and any art installations increases our observational skills and allows us an opportunity to practice the interpretation of visual images.  By engaging with the story behind the picture we try to discover our own reactions and in group discussion we have the opportunity to explore these feelings further.
Our visit to the Newspeak exhibition stimulated important discussion about important aspects of contemporary medicine which may not be encountered elsewhere in the medical curriculum. We may not have been able to understand it all the exhibits but certainly some of the pieces we looked at in the Newspeak exhibition were wonderful. We came away feeling we had risen to the challenge that modern art had presented and as a result expanded our horizons.

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Oncologist Sam Guglani wonders what medical care really means

Care infuses medicine. Well, the word ‘care’ infuses the language of medicine – Healthcare, Intensive Care, Palliative Care, Standard care, Standard of care, Best supportive care, Care Quality Commission. But what actually is medical care?Good medical care perhaps primarily describes the quality delivery of evidence-based therapeutic interventions, for example drugs, operations, scans, anaesthetics, and the organisation of services to permit these. It must also necessarily refer to the judgments around such interventions, that is to say the ethical consideration towards appropriate medicine. A skilfully performed pneumonectomy may not reflect good medical care in a patient dying from advanced lung cancer, for example. It seems reasonable then, to suggest that good medical care demands quality clinical medicine and ethical judgment. That the former requires rational thought may not come as a surprise, but the latter? In fact, contemporary ethics and moral philosophy place reason and rational thought at the core of what it is to make moral judgments and act ethically.
However, schools of ethical thought don’t always agree on what it is that constitutes the basis for moral action in medicine. For example, lying to patients may be considered to be bad because lying is bad in principle, or good if the lying perpetuates good outcomes such as hope, or bad again if the consequences, despite the good outcome of hope, generalise towards the negative, such as an erosion of trust.  Further to disagreeing on the basis for moral arbitration, the centrality of ‘reason’ may be questioned. ‘Care ethics’ gives weight, beyond rational thought, to the place of sympathy, emotional understanding and relationships in informing ethical judgments (Beauchamp and Childress 2001, p. 369)
Jonah Lehrer, in his book ‘The Decisive Moment’, describes the place of emotional understanding in morality:  ‘At its core, moral decision-making is about sympathy. We abhor violence because we know violence hurts. We treat others fairly because we know what it feels like to be treated unfairly. We reject suffering because we can imagine what it’s like to suffer.’ (Lehrer 2009, p 174) He goes on to elaborate on the evidence for emotion having a central role in ethical judgment and paints a very interesting picture in aligning often very rational thinking with clear acts of immorality. Even so, what about this, the idea of sympathetic and compassionate care in medicine?
Well, firstly, it seems as though, unlike the parameters of clinical/ technical care in medicine, compassionate care is harder to measure. Technical care is relatively easily measured and to a certain extent such data form the basis of the new outcomes framework for the NHS.  Healthcare staff in general and doctors in particular recognise this and to a certain extent aspire towards it. For patients and relatives, these data may be more opaque, unless significantly removed from the mean. As such, responsibility for judging, monitoring and delivering technically good care may be readily handed over to the profession.
Compassionate and empathetic care is harder to measure and in many respects therefore it just isn’t. Where currently is the section in our appraisal folders entitled compassion?  Doctors seem to value it much less and indeed we almost feel uncomfortable when discussing it.  Patients and families though, recognise this much more readily and indeed are generally very sensitive barometers of it.  Their assessment is probably more reliable, consistent and reproducible than any parametric measure we might use.  We all know (and can recognise ourselves when we become patients) the health worker who cares.
Such care can be a simple and empirical prompt towards good medicine, through sympathetic imagination: how would we want our family or indeed ourselves to be managed in such a situation? Of course this isn’t enough and is potentially open to abuse. But so is a version of medicine informed simply by good technical skills or good ethical judgment.
Compassionate and sympathetic care is arguably a primary prompt and governing steer for the entirety of good medical care. And it is the platform for engaging patients at times of often profound vulnerability. It might motivate finding the bed, asserting the need, chasing the results, over-booking the clinic, calling the family, developing the service, asking for opinions, clarifying all the evidence, seeking consensus, admitting the uncertainty and withdrawing the treatment. It is antithetical to hubris and necessarily connected to a proper medical professionalism, one founded upon a duty to patients rather than the rights of a privileged set.
How do we teach and foster this care? By recognising its importance – now more than ever in a resource -constrained, exponentially more technical NHS with increasing demand and possibility. By selecting students, training doctors and consultant appointments with this in mind. And, perhaps most challenging, but also most pressing, by decanting it through professional example.

References
Beauchamp, T. and Childress, J. (2001) Principles of Biomedical Ethics, Oxford, Oxford University Press
Lehrer, J. (2009) The Decisive Moment, Edinburgh, Canongate

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