Educating Doctors' Senses Through the Medical Humanities

"How Do I Look?"

Alan Bleakley

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429536045
• Edition: 1
• Topic: Médecine
• Subtopic: Formation en médecine

How Do I Look? Educating Doctors' Senses Through the Medical Humanities uses the medical diagnostic method to identify a chronic symptom in medical culture: the unintentional production of insensibility through compulsory mis-education. This book identifies the symptom and its origins and offers an intervention: deliberate and planned education of sensibility through the introduction of medical humanities to the core undergraduate medicine and surgery curriculum.

To change medical culture is an enormous challenge, and this book sets out how to do this by answering the following questions:

• 
  
  

• How has a compulsory mis-education for insensibility developed in medical culture and medical education?

• 
  
  

• How is sensibility capital generated, who 'owns' it, and how is it distributed, mal-distributed and re-distributed? What is the place of resistance (or 'dissensus') in this process?

• 
  
  

• How can the symptom of a 'developed' insensibility be addressed pedagogically through introduction of the medical humanities as core and integrated curriculum provision?

• 
  
  

• How can both the identity constructions of doctors and doctor-patient relationships be tied up with education for sensibility?

• 
  
  

• How can artists work with clinicians, through the medical humanities in medical education, to better educate sensibility?

The book will be of interest to all medical educators and clinicians, including those health and social care professionals outside of medicine who work with doctors.

1 Medicine making sense

The senses as a system

Transforming a burden, shaping doctors

An article in The New York Times recounts how dealing with patients close to death on a day-to-day basis began to take its toll (Puri 2019: unpaginated). The palliative care doctor Sunita Puri struggled with “how to doctor patients I knew I would lose”, as he grew “progressively more anxious, and occasionally despondent … more withdrawn, less punctual and occasionally distracted”. Puri’s numbing of feelings, creeping anxiety and foggy depression are also the most common symptoms shown by doctors who over-identify with patients and are exhausted as a consequence. Further, the health care system can alienate, grinding one down. And it can create anomie where it appears that you are working in a culture providing little moral guidance, or one that has lost its own moral compass.

For the few, this numbing can rapidly tumble into burnout (Peterkin and Bleakley 2017), an unfortunate descriptor for what is better compared to cold ashes. For the many, in order to function on a daily basis such emotional perturbations are psychologically ‘managed’: repressed, projected, or sublimated, only to return in a distorted form as disillusionment, bitterness and exhaustion. Here, a switch to part-time work and/or early retirement may be the only way to deal with this burden of negative affect. Puri himself was tipped particularly, he says, by not understanding “why death had come for a 35-year-old mother of three with a rare cancer”, and “why a marathon runner was dying after a sudden heart attack when he had been a marathon runner”.

When his “sadness grew stronger”, Puri was warned by colleagues that, in general, doctors do not look after themselves well, and he should try a relaxation technique or psychotherapeutic intervention. However, “massages, therapy, hiking and meditating under the shade of Marin County redwoods” did not help him. What did help – indeed was transformative – was a chance visit to a Vietnamese Buddhist temple near the hospital where he worked. Here, a group of Tibetan monks were “hunched over a table” creating a sand mandala – an intricate, coloured geometric flower ‘painting’ made by collaborative, cumulative and careful pouring of small amounts of sand. This meticulous creation took many days to complete, but once finished and serenely contemplated, Puri was shocked that one of the monks took a brush to the work and, without remorse, quickly swept the sand into bags. As Puri notes, “the hands that created it were content to let it go”. Buddhism teaches us to accept that all is change.

This lesson on impermanence – clearly appropriate to end of life care – had a lasting effect on Puri. In contrast to interventions from medical education, psychotherapy and mindfulness, a visual and performative art form and spiritual practice – a “painstakingly crafted mandala … ablaze with colour” – mediated how Puri could “doctor my dying patients differently”. He would still feel compassion for patients but “didn’t leave work … consumed with grief, withdrawn and disengaged”. This lesson on impermanence then transformed not only Puri’s care of his patients but also his growing existential angst and ‘bad faith’ in coming to doubt the authenticity of his own practice. Instead of fixating on their “tragedy”, carrying this personally as a burden, he would change immediate things such as “easing breathlessness and agitation” for dying patients, and explaining things better to “despondent families”. This shift to valuing “the circularity of things” breathed new life into Puri, perhaps stemming burnout.

Puri also models Michel Foucault’s (1982: 351) advice, that “From the idea that the self is not given to us, I think there is only one practical consequence: we have to create ourselves as a work of art”. Meaning is made by ‘self-forming’ as an art form rather than through instrumental labour such as ascending an occupational hierarchy. Self-forming here is not refining appearance, but rather refining the senses for closer noticing and appreciation of the world. It is not how one ‘looks’ but how one looks at (or rather, with) the world.

This heart warming tale is of deep importance in the context of this book, where Puri’s recovery was facilitated by aesthetics (the meditative making and unmaking of the mandala) and not by functional or instrumental psychological technique. While this is an idiosyncratic tale, it does have wider resonance for medical education. Puri’s senses, dulled by the nature of his work, almost certainly clouded by the return of repressed distress, were cleansed by an instant of contemplation of beauty and form linked to a phenomenological insight into the nature of transience. The senses were re-educated through the art of the mandala-making and subsequent sudden (even shocking) undoing – even as contemplative observer rather than participant. This was directly translated into improved patient care as Puri re-framed what his work was about: ‘holding’ a space for his dying patients in which he did not have to personally bear the burden of tragedy, but rather bear witness to this. Buddhism calls this ‘letting go’ and insists that this is an embodied sensual experience and not just cognitive. Making the mandala is evidently tactile as well as visual, and the sand surely has a characteristic odour and even a sound as it is poured.

Puri’s revelation was deeply personal, idiosyncratic and of the moment. While we need not take it literally as a lesson for medical education (compulsory sand mandalas for all!), we must take it seriously as illustrating the power and beauty of exercising the senses. This book embraces and celebrates the body-sensual work of medical practice at a time when sensory work in medicine is described as being in ‘crisis’ (Maslen 2016).

To be more exact, Sarah Maslen (ibid), from ethnographic studies of how doctors work with the senses, describes a “crisis of legitimacy” in “sensory work of diagnosis” in an age of increasing medico-legal pressures, where ‘warm’ hands-on diagnostic work is rapidly and literally being taken out of doctors’ hands by ‘cold’ technologies and testing. (Further, there is the threat of litigation accompanying a new climate of acute sensitivity around inappropriate touch.) While technologies are welcome in terms of accuracy of diagnosis, the unintended consequence of their use is to gradually sideline the sense-based practices and traditions of the medical encounter that not only provide an array of diagnostic practices but also afford a medical education nexus for the identity construction of doctors. Maslen is just one of a number of commentators, amongst them physicians such as Martina Kelly, Roger Kneebone and Abraham Verghese, who bemoan the erosion of what is traditionally referred to as hands-on ‘bedside medicine’.

But the erosion of hands-on medicine in the face of technologies is not the primary focus of this book, although it provides an important sub-theme. My main concern is that many conventional strands of undergraduate medicine – such as learning anatomy through cadaver dissection, learning communication skills through simulation and learning clinical practice through both subtle and overt ritual humiliation – do not open up the senses but close them down. In contrast, better medical schools do not expose students to such pedagogical flaws, and this should be celebrated. My plea is that all medical schools should critically interrogate and change their methods where this leads to the mis-education of insensibility and insensitivity. Passage through the medical school culture forms students’ medical perceptions as sensible refractions.

Refraction

In Section XII of An Enquiry Concerning Human Understanding, the Scottish philosopher David Hume (1748) discusses scepticism in relation to the evidence of the senses. Sceptics, notes Hume, argue that our senses are imperfect or fallacious, based on phenomena such as “the crooked appearance of an oar in water”. This phenomenon of refraction (light bending) suggests that

senses alone are not implicitly to be depended on; but that we must correct their evidence by reason, and by considerations, derived from the nature of the medium, the distance of the object, and the disposition of the organ, in order to render them, within their sphere, the proper criteria of truth and falsehood.

In other words, the senses are not independent of the perceived world but affected by that world, and are subject to the exercise of the mind. The senses, for example, can be engaged or disengaged through education. We can take refraction as a metaphor for the education of medical students as they become junior doctors. Like the oar of David Hume, the embodiment of medical students in medical culture, their sense-immersion, offers a refraction through that culture so that they appear in their professional roles as different not only to the layperson as patient but also to themselves. The emerging persona of the doctor must be given ‘face’ both aesthetically and ethically, so that the doctor can claim ‘I look differently’, referring to medical expertise, and also ask: ‘how do I look?’, referring to subjectivity and identity. As a medical education is primarily a socialisation, so the nascent doctor also notices that he or she ‘looks different’ as she learns to ‘look differently’ through acquisition of the diagnostic gaze (see Chapter 9 in particular). As senior students and junior doctors, medicine begins to make sense as perceptions are refracted through the increasingly familiar and familial medical culture.

Re-thinking the human sensorium

Here is a patient in a diabetic coma, described by Abraham Verghese (2010): “His breathing was deep, loud, and sighing, like an overworked locomotive. With every exhalation he gave off that sweet emanation – it even had a color: red”. This synaesthetic diagnosis should be enough in itself to warn us against a false compartmentalising of the senses. Rather, let’s imagine the senses as a dynamic, complex adaptive system with components (senses as ‘attractors’) working for each other. It is purely for convenience that in subsequent chapters I separate them out. Division into different senses is a rhetorical gesture for ease of understanding.

This chapter discusses philosophical, psychological and biological models that challenge both compartmentalising the five senses and imprisoning them inside the individual. Again, the human sensorium is treated as an ecology, a system, with senses working in tandem. Notions such as ‘extended senses’ are introduced, relating to ‘shared-sense’ collaborative work in communities of practice and complex, fast-moving and entangled health care embodying critical exchanges that Yrjö Engeström (2008, 2019) has termed “knotworking” as tying, untying and retying what may otherwise remain as separate threads of activity.

We must go beyond the separation of the traditional ‘five senses’ to knotwork these, through differing attractors such as kinds of attention and vigilance that organise sense impressions, remembering that there are five identifiable senses alone of touch (‘crude’ or everyday touch, pressure, cold, heat and pain) beyond proprioception, which is the awareness of one’s body in space, and interoception, which is the sensing of the body’s interior working; and we must account for the shaping or tuning of the senses by historical and cultural factors.

Finally, we must note a bias to the visual, an ‘ocularism’, in turn shaped by a dominance of individualistic Western psychology (Jay 1993). Rather, we have a rich tradition of ‘intersense’ (David Howes 1995, 2003) to draw on. Aristotle talked of an integrative ‘common sense’, and Heller-Roazen (2007) has extended this to mean the sense that one is alive. Merleau-Ponty (2012), the father of phenomenology, suggests that we focus upon a lived body that does not have senses but is sensible.

The augmented senses

To limit the senses to oneself as an individual is a category mistake. First, the senses are not what define me – we cannot privatise the senses – but what locate me in, and connect me to, the wider world. The senses are then extended and social. Thus, social learning approaches such as Activity Theory begin with the assumption that learning is ‘object oriented’ and not subject oriented, where the object shapes the learning and subjectivity (Engeström 2019). Second, the senses are augmented and extended by technologies that are culturally determined. Most obviously, glasses correct my own sense of sight, and the computer and mobile phone heavily augment my senses.

Fredriksen (2002: 71) argues: “The success of modern medicine is closely related to its ability to transcend the human senses”. A paradox of the human condition is that we take on trust what our senses tell us, but of course what is perceived directly cannot always be trusted – the most obvious example of this is that vision to the horizon tells us that the earth is flat, and we have no sense also that the earth is moving. A stick appears to bend in water (refraction) when we know that it is straight, as David Hume explores above. Similarly, autopsy findings, imaging and ultrasound reveal what the bare senses may miss or mistake for symptom and cause of symptom. Thus, we must think of the senses now as an augmented and extended system. This situation has been described as raising a conundrum for medical education where medical students become less able to rely on the evidence of their own senses as the augmented senses dominate diagnostic work. But, as this book shows, the education of the ‘natural’ senses for sensibility and sensitivity affords something beyond cold diagnostic capability – that of warm human contact and development of embodied trust.

Medical education has been dominated for at least half a century by forms of cognitive psychology. This has debrided the senses and it is time we came back to our senses. Medicine is unique in its powerful yoking of abstract science and hands-on sensory practice. Just as medicine deals with the bodies of patients, so medical education should get out of its head and return to the body. This embraces technological extensions to the body that have replaced the fallible human sensorium with reliable instrumentation such as apparatus to measure blood pressure, and dissecting sets and improved microscopes for histological work.

The shift from a first-hand, sense-based experience to precise quantitative measurement mediated by instrumentation is often presented as a shift in pedagogy from direct perceptual experience to mediated analysis. In 1908, the physician and educator Richard Cabot (2018) had formulated a diagnostic method in the absence of the patient where “it is easier to concentrate attention upon the processes of memory, comparison, and exclusion, which form the essence of diagnostic reasoning, if the senses are not distracted by the presence of the patient”. Thus, “After the student has learned to open his eyes and see, he must learn to shut them and think, and when he is thinking the less he has to distract him the better” (italics in original). Here is Cartesianism in full bloom, rejecting an embodied medicine. In this reading, medical students lose an education of the senses and gain analytical prowess. But such reductionism is literally a non-sense – both cognition and embodiment are necessary in medical work as a whole ‘body-mind’. Here, the body of medicine has shut down its interoceptive and prop...