John Stezaker and the Medical Profession

British artist John Stezaker takes portraits and various landscapes and questions conventional understanding of lines and flow. He creates collages of seemingly contrasting pictures into curious, coherent and captivating images, in this exhibition of various collections of his artwork. A few of us from the medical humanities course attended his exhibition held at Whitechapel Gallery (on till 18Mar11). This blog posting is an analysis of some of the images and their possible interpretations applicable to the medical profession.

Stezaker is perhaps best known for his Mask series which fuses celebrity portraits with landscapes and makes the stones and trees do the talking instead of eyes and mouths. A side-profile picture of a man and woman close to kissing have the fronts of their faces replaced by a picture of a gorge, one with straight edges, perhaps signifying no intimate connection actually exists. The same picture is then collaged with a gorge with overhanging trees and shrubs, hinting the possibility of growing into each other and a mingling of personalities, physical touch or mental connection. Such concepts could be applied to the changing nature of the doctor-patient relationship. The traditional lab-coat-wearing doctor with the paternalistic attitude is reminiscent of the straight-cut gorge. But this is slowly being replaced by the down-to-earth, rapport-building, patient-centred attitude, more similar to the image with the mingling of tree branches and shrubs between the gorges. In the words of Anatole Broyard, “How can a doctor presume to cure a patient if he knows nothing about his soul, his personality, his character disorders? It’s all part of it.”

The smaller series entitled Fall, fuses naked frontal and back photos, split along the length of the body, of man and woman. The uncanny similarities between both male and female body shape and lines flow almost seamlessly into each other (discounting the obvious cut down the middle of the image), but the intriguing part is the question of the purpose of the title. Perhaps the artist is hinting at sexual ambiguity and promiscuousity being the fall of mankind. However, such practices have been the talk of the town even in ancient biblical days of sex-shrines and sex-based religions, and despite fear of being taken out of context, the androgyny or fertility practices of Deuteronomy 22:5 "A woman must not wear men’s clothing, nor a man wear women’s clothing." Doctors are required to be thorough and probe into the sexual history of patients without being judgemental. Yet such topics are never taught sufficiently in medical school.

In his Marriage series, Stezaker joins cut portraits of different celebrities, either male-female, male-male or female-female, joining certain important lines to create on first glance almost schizophrenic images. Some of these were immediately visually appealing, but my eye took a little longer to adjust and consider the beauty of others. The brilliance of this series is probably in the way he makes some important facial landmarks meet so that it still retains a certain flow within the images, yet throwing out the rule that symmetry is intrinsically more appealing. Some of these portraits resemble burns victims I have seen in hospitals, due to the asymmetry of the faces and heavy wrinkles on one side but young smooth skin on the other.

Others combine "masculine" and "feminine" features, blurring the line between what we perceive as male and female. Again this may signify social stereotyping and draw attention to our own assumptions about others. Skin and especially facial irregularities are the subject of discrimination, ostracisation and bullying, resulting in self-esteem and massive psychological issues, to the extent of the desire or requirement of cosmetic, reconstructive or other surgery or medical intervention. However, it is arguable if surgical or medical intervention really do address such issues sufficiently, since it seldom gets to the root of such problems. Mostly, doctors tend to shy away from attempting to address the emotional/psychological/spiritual root of such problems, either because it takes too much energy and time, because we prefer to maintain an exclusively "professional" relationship, or because we are not taught and are under-developed in dealing with such issues. From this series of images, perhaps we can learn to appreciate unconventional beauty in our everyday practices and contact with patients, without which it is difficult to genuinely care for our patients.

More curious was the series Tabula Rasa. This is the theory that individuals are born without built-in mental content and knowledge comes from experience and perception, in a sense, the age-old nurture versus nature debate. In this series, polygonal shapes are cut out of pictures; in a picture with a man talking to another two, the heads of the two people are cut out in the polygonal shape, likewise with a picture of a man talking to a woman. The obvious suggestion is the concept of a clean slate when meeting another person, which is analogous in a medical context to every new consultation and patient. Without any details of the entire heads of these people in the pictures, the viewer is left to perceive the faces of these people, as if making heavy use of Gestalt's theories of perception, a psychological concept of visual recognition and interpretation. Too often, medical professionals have preconceptions of patients based on what they look like when they first step into the consultation room. These often then colour our perception of the cultural and societal status of the said patient, and alters the way we think of differential diagnoses, or in private healthcare systems, whether they are even offered more expensive drugs and therapies (I'm drawing this on friends' experiences in other countries). To take patient-centred care seriously then, we should perhaps train ourselves to rely less on visual judgement of people, favouring a more "tabula rasa" approach to patient contact and the doctor-patient relationship. Only then can we start to attempt to actually be non-judgemental and compassionate doctors.

Stezaker's collection in the Whitechapel Gallery challenges our perceptions of beauty and judgements of others, and its concepts may extend well into the medical sphere. There were plenty of ideas and interpretations within the group of medical students who went to the exhibition, and these are just a selection of some of them (mostly my own interpretation and experience).

*All pictures copyright of John Stezaker. Used here only as example illustration.*

Dance and Medicine

The mid-point of medical residency is probably the bleakest point in medical training. The daily grind of death and disease wears young doctors down, and the end of residency seems impossibly far off. In the second year of my residency at Bellevue Hospital, I began taking dance class at the Martha Graham studio in Manhattan. It turned out to be an unexpectedly visceral lifesaver for me.

Here is an excerpt from the essay, “Pas de Deux,” which appears in the new anthology from “Becoming a Doctor,” edited by Lee Gutkind. (Norton, 2010.)

“One day, after a long night in the ICU, I rushed straight to dance class, leotards under my scrubs. I had spent the bulk of my last thirty hours with Nilsa, a young woman dying of HIV. Nilsa’s body was ravaged by bacterial, viral and fungal infections. The body cavities that weren’t drowning in their own fluids were hemorrhaging blood. Her temperature never dipped below 103°. The breathing machine provided oxygen in exchange for her tuberculosis-laden breaths. I injected sedatives when she convulsed, her water-logged lungs laboring to absorb more oxygen. The nurse and I arranged icepacks around her burning skin, but they melted rapidly. Her death was slow and brutal. Her mother, two brothers, and aunt sat with her, weeping into their protective respiratory masks.

I limped out of the hospital after signing Nilsa’s death certificate. There were so many infections that I couldn’t decide which one to write for “immediate cause of death.” My sleep-starved body longed for bed, but my aching soul dragged my protesting limbs to East 63^rd Street.

We were doing the plié-relevé series, a set of exercises that I have always found particularly beautiful. There is one point, in fifth position, in which the drama builds until the climax occurs with just one simple motion: a 90° twist of the body while lifting into a relevé, one arm scooping an arc into the sky. In one brief, but compelling, moment, the whole class rises into the air as a single being, sweeping its focus from the one corner of the room to the other. Physically subtle, yet emotionally dramatic, almost more so for the understatement of the movement.

…I look back now and realize that it was the continual infusion of the aesthetics of dance that helped keep me alive throughout those draining years. After each daily dose of agony and suffering, I needed not only to witness beauty, but to participate in beauty. I was well aware that I couldn’t possibly approach the feats of the advanced dancers, but that turned out not to matter at all. It was enough just to be a bit player in that world, to be a miniscule stitch in that weave of beauty.”

Reprinted from “Pas de Deux” by Danielle Ofri, from “Becoming a Doctor,” Gutkind, L., ed. ©Norton, 2010.

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Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients.

View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.

Poetry in Medicine

When I make rounds with my students and interns, I always try to sneak in a poem at the end. I think poetry is important because it helps convey the parts of the medical experience that don’t make it into textbooks. It’s important because it teaches creative thinking—something of immense value to doctors.

It’s important because interpreting metaphors is a critical clinical skill in diagnosis; patients’ symptoms often present in metaphorical manners and we doctors need to know how to interpret our patients’ metaphors. Last but not least, there is a therapeutic value to introducing beauty into a situation that is not commonly associated with aesthetics.

I’ve been giving poetry to my medical team for a few years now, but I’ve always wanted to give poetry to my patients. Unfortunately, English is not the first language for most of the patients in my hospital, so this has been challenging.

But there is one set of patients that seems to consistently speak English—the alcoholics. The Bowery-type alcoholics aren’t necessarily the favorite patients of the interns. These patients are frequent fliers, they are clinically “uninteresting,” they are often malodorous, and their illness is perceived as self-inflicted. But they do speak English.

So one morning on rounds, our team went to examine a new alcohol-withdrawal admission. His condition was standard: alcohol-on-breath, speech slurred, fingers trembling, hair and beard disheveled, body odor a mix of unwashed socks and cheap beer. He was cranky, and impatient with the detailed questions we asked.

As the team was finishing up, I whipped out some papers from my pocket—Jack Coulehan’s poem “I’m Gonna Slap Those Doctors. I gave a copy to the patient and distributed the rest to the resident, interns, and medical students. Asking their forbearance for this slight divergence from medical protocol, I plowed onward and read the poem aloud.

I’m Gonna Slap Those Doctors

Because the rosy condition

makes my nose bumpy and big,

and I give them the crap they deserve,

they write me off as a boozer

and snow me with drugs. Like I’m gonna

go wild and green bugs are gonna

crawl on me and I’m gonna tear out

their goddamn precious IV.

I haven’t had a drink in a year

but those slick bastards cross their arms

and talk about sodium. They come

with their noses crunched up like my room

is purgatory and they’re the

goddamn angels doing a bit

of social work. Listen, I might not

have much of a body left,

but I’ve got good arms -- the polio

left me that -- and the skin on my hands

is about an inch thick. And when I used

to drink I could hit with the best

in Braddock. Listen, one more shot

of the crap that makes my tongue stop

and they’ll have something on their hands

they didn’t know existed. They’ll have time

on their hands. They’ll be spinning around

drunk as skunks, heads screwed on backwards,

and then Doctor Big Nose is gonna smell

their breaths, wrinkle his forehead, and spin

down the hall in his wheelchair

on the way to the goddamn heavenly choir.

(from Medicine Stone, 2002. © Jack Coulehan, reprinted with permission)

As I read the poem, I could feel the atmosphere in the room changing, ever so slightly. The focus shifted from the patient to the poem, and everyone was an equal neophyte with this particular poem.

When I finished reading, some of the medical team looked uncomfortable, but the patient was smiling broadly. “This is great,” he said. “I love it!” With his pronouncements, everyone relaxed a bit.

“You know,” the patient continued, seemingly happy to have an audience, “ I used to read some books, back in the day.” He sat up in bed, more animated now. “I like history stuff—ancient Greeks, ancient Romans. Real characters, those guys.”

We ended up having a conversation about his childhood in small-town New Jersey, how he cut classes in high school to putter around on the beach.

We left the room feeling awkward but also somehow lighter. Suddenly our patient wasn’t just another alcoholic drying out on the ward. He was a real person, someone who stood out in our minds.

The poem certainly didn’t change the course of his devastating disease of alcoholism. It didn’t offer him the epiphany to suddenly quit drinking or to reconnect with his estranged family. His liver enzymes didn’t miraculously normalize. His platelets didn’t bound back to health. But it gave all of us a sense of human connection.

Throughout his four-day stay in the hospital, the patient was much more pleasant to the team. I noticed that the students and interns wandered in more frequently to say hello. We all felt just a bit more connected.

Rx: Take two sonnets and call me in the morning.

If you are interested in poetry and medicine, check out this unique conference at Duke University on May 21-23. Life Lines: Poetry for Our Patients, Our Communities, Ourselves. (I will be giving a presentation there.)

Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.

Why Nobody Likes Surgery

PorcelainCowlickBoy doesn't like surgery. In fact, he hates surgery so much that he's posted a film about it for all to see. Exploring patients' experiences in theatre through a series of images and sounds that highlight the invasiveness of operations, we have a powerful sense of why many people would rather not be put under the knife.

What do you think?

NB This video contains images of blood and invasive procedures which you may find disturbing.