Adding a Dose of Fine Arts

When it comes to diagnosing what’s wrong in a patient, medical schools are increasingly telling students to look for answers in some unexpected places: in novels, paintings, dance and theater.

Technical training remains the heart of medical education. But the number of future doctors taking literature, art interpretation and other humanities courses has surged over the past decade. They are trying to awaken their feelings and intuition as a way to connect with patients who often feel as though they’ve been reduced to a collection of symptoms.

Educators say the distilled emotions and insight in the arts offer students a crash course in the old-fashioned skill of the bedside manner. Art, they say, is a textbook on the human condition.

“What we are dealing with here is the art in the art of medicine,” said Brownell Anderson, an executive with the Assn. of American Medical Colleges.

This year, more than three out of four medical schools offered humanities coursework alongside such staples as molecular biology and neuroscience. In the early 1990s, only about one out of three did.

Yale students study paintings at the university’s Center for British art to enhance their observational skills. At New York’s Columbia University, trainees read Tolstoy’s “The Death of Ivan Ilych” as a primer on suffering -- and to sharpen their abilities to interview and listen. At UC Irvine, anatomy students write essays about their cadavers, imagining who they were in life, before taking them apart.

“The medical education system gives students the message that what’s important is memorizing textbooks,” said Johanna Shapiro, a psychologist who started the medical humanities program at UC Irvine five years ago. “To be a good doctor, they have to draw on every resource they have, including what’s inside themselves. Science is simply not enough.”

In the traditional boot-camp world of medical school -- where students spend countless hours digesting scientific facts -- the humanities were once seen as having nothing to do with treating the sick.

“We talk tongue-in-cheek that when a student moves from his pre-med to his medical school years, he is moving from the pre-cynical to the cynical years,” said Dr. Abraham Verghese, an infectious-disease expert and best-selling author who last year began a medical humanities program at the University of Texas in San Antonio.

UC Irvine student David Santos, 26, found medical school left him no time to pursue his passion for painting. “It’s been really hard to come back full circle and feel some of the creative juices I once had,” he said. “Medical school dehumanizes people.”

Time was, a doctor might taste a patient’s urine for sweetness and confirm diabetes. But sophisticated diagnostic tests, tiny scopes and surgical tools and body scans have rendered such intimate techniques obsolete. Today, it’s possible for a doctor to treat a patient without ever laying hands on him -- or even looking him in the eye.

Dr. Irwin Braverman, who leads the art class at Yale’s medical school, recalls a patient with unexplained tumors on his legs. A resident, told in advance what the complaint was, walked in and “saw a person, a blob, and he immediately looked at the legs,” Braverman said. The tumors provided no clue as to their cause; a biopsy would only narrow the possibilities.

Braverman saw something else. The patient had bulging eyes, which combined with the tumors, told him the man had thyroid disease.

“Doctors rely more on technical imaging devices than the eye,” Braverman said. But a 2001 study published in the Journal of the American Medical Assn. found students who studied paintings in his class were 2 1/2 times more likely to notice subtle diagnostic details in patient photos than students who hadn’t taken the class.

In a 2001 Gallup poll of more than 45,000 U.S. patients, respondents gave their doctors high marks for care and compassion, but significantly lower marks for communication skills.

“They said, ‘How can you diagnose me if you didn’t give me a chance to talk and you didn’t listen? And if I do tell you something, you interrupt me?’ ” said Rick Blizzard, a health-care consultant who analyzed the data.

Doctors feel frustrated too.

“The traditional rewards for medical practitioners have diminished. They don’t make as much money as they once did; they don’t have the status in the public’s eye as they once did; they’re hounded by clerks from the insurance company,” said Dr. Rita Charon, who teaches humanities at Columbia University’s medical school. “Doctors are asking themselves, ‘What are the real, fundamental rewards of taking care of sick people?’ ”

One answer, Charon said, is for medical schools to use the arts -- particularly literature -- to teach doctors how to engage sick people in a way that deepens their understanding of the patient, their illnesses and ultimately themselves.

Charon was awarded a 2002 Guggenheim fellowship to continue her research into what she calls “narrative medicine” -- the way in which studying the emotions in literature can sharpen a medical student’s ability to make a diagnosis by “reading a patient’s story” through observation, listening and expository writing.

Charon writes up her notes from patients’ visits in narrative form, then asks them to critique her version of their story and fill in the blanks. “Our traditional methods of diagnosis are good at picking up, say, anemia,” she said. “They’re not very good at picking up clues in a patient’s personal history and emotions that could be causing a physical ailment.”

The study of literature is the foundation of medical humanities, and for good reason. Medicine and literature have long been intertwined.

Illness and suffering are the subject of countless classics. Anton Chekhov, Somerset Maugham, William Carlos Williams, Arthur Conan Doyle and Walker Percy all wrote novels informed by their training as physicians. William Osler, whose 1892 textbook “The Principles and Practice of Medicine” helped revolutionize its study, argued that prospective doctors should be as well-versed in literature as they are in science.

But it was the 1910 publication of the Flexner Report, a Carnegie Foundation study, that had the greatest impact on how U.S. doctors are trained. The report advocated the German model of tough admissions standards and an education steeped in the hard sciences. It’s essentially the model used today.

“The first two years of medical school is all about swallowing and memorizing a tremendous amount of material that’s boring and stultifying,” said Richard Selzer, a former surgeon and Yale professor who has written 10 books, many based on his work in the operating room. “I’m not anti-science or anti-technology, but this emphasis on science has outstripped our ability as human beings to function in a humane way with patients.”

In recent years, Selzer, 74, has been in demand as a guest lecturer at medical schools. His books -- particularly the memoir “Letters to a Young Doctor,” in which he bares his emotions, fears and failures -- are standard reading in medical humanities courses.

Selzer hasn’t always been so popular. When he was first published in the 1960s, only one U.S. medical school taught humanities. He said colleagues kept their distance for years, believing he was “revealing secrets” that swept away the pedestal of unchallenged authority on which physicians stood.

“My colleagues would say, ‘What’s the matter with you? ... Why are you telling people what it feels like to lay open a body? What it feels like to fail on the operating table?’ ” Selzer said. “The feeling was ... to take on that responsibility and try to save a life, one has be anesthetized from the heat of the event.”

As recently as 25 years ago, a student’s ability to get into medical school could be jeopardized if his or her undergraduate transcript showed too much interest in literature, writing or the humanities, the Assn. of American Medical College’s Anderson said.

Yet in the past five years, several literary journals have popped up in unexpected places -- attached not to university English departments, but to their medical schools.

The awareness also can be seen in the Medical College Admission Test, which the AAMC administers. Since 1991, the test has included an essay component to attract students with talents beyond mastery of chemistry and biology.

In fact, many of the test’s essay topics seem better suited to a philosophy major: Creative inspiration, rather than careful planning, often results in the solution to a problem. The more people rely on computers, the more people become alienated from one another. Violence is sometimes necessary to achieve social change.

“Stories -- that’s how people make sense of what’s happening to them when they get sick. They tell stories about themselves,” said Dr. Howard Brody, a family practice physician and professor at Michigan State’s medical humanities program. “Our ability as doctors to treat and heal is bound up in our ability to accurately perceive a patient’s story. If you can’t do that, you’re working with one hand tied behind your back.”

Brody remembers a middle-aged construction worker who came to him with chronic back pain. Brody told the man he needed a new career, that he was past the day he could wrestle a jackhammer for a living.

The patient resisted. So Brody asked him to write two essays: one describing his life in five years with back pain, the other describing what life would be like pain-free.

“I discovered that the construction firm he worked for was his father’s firm, and that his twin brother also worked for the firm,” Brody said.

“Essentially, I was asking him to divorce himself from his family. I realized I had to change my treatment goals. This was not about making a career change. I felt I had to help him manage his pain.”

Sounds simple. But in the crush of a busy medical practice, such patience is hard to maintain -- even for someone who teaches it, Brody said.

He tells of the woman who suffered from severe depression and chronic pain brought on by a ruptured disk and other physical ailments. Brody prescribed one anti-depressant after another, but each triggered side effects.

Finally, she went to a psychologist who specialized in physical pain. He had her write letters to her estranged daughter and to her parents, who had recently died. The act purged her of pent-up demons that pharmaceuticals could not.

“I sat there with egg on my face,” Brody said. “I mean, I’m the guy who is into writing. It reminded me how easy it is to forget about this.”