24/7/365
The International Journal of Healthcare
& Humanities
© Faoud Ishmael, M.D.
Volume Six • Number Six • Fall 2011
Penn State University College of Medicine
Department of Humanities
24/7/365
The International Journal of
Healthcare & Humanities
Volume Six • Number 6 • Fall 2011
Penn State College of Medicine • Department of Humanities
Penn State University, Department of Humanities ISSN: 1941-5613
The Journal is also published in electronic form by the Penn State
University Libraries. http://publications.libraries.psu.edu/eresources/ijhh
ISSN: 1941-5621
©
Editor-in-Chief
Cheryl Dellasega, C.R.N.P., Ph.D.
Professor of Humanities
Penn State College of Medicine/Hershey
Professor of Women’s Studies
The Pennsylvania State University/University Park
Ronald Domen, M.D.
Poetry Editor
Professor of Pathology, Medicine, and Humanities
Penn State College of Medicine
Daniel George, Ph.D.
Dissertation Abstracts Editor
Department of Humanities
Penn State College of Medicine
Deborah Tomazin
Managing Editor/Graphic Designer
Department of Humanities
Penn State College of Medicine
The IJHH Journal is published biannually and subscription cost is $15.00.
Orders for new subscriptions or single issues should be sent to:
Penn State College of Medicine
Department of Humanities, H134
500 University Dr., P.O. Box 850
Hershey, PA 17033-0850
On The Cover:
Faoud Ishmael, M.D.
Content
Letter from the Editor.......................................................iii
Three Hours Later..............................................................1
Stacey Nigliazzo, R.N.
The Physician as Poet.........................................................2
Ronald E. Domen, M.D.
A Door...............................................................................7
Wynne Morrison, M.D., MBE
Humanities in a Rapidly Aging World:
The TimeSlips Project at Penn State College of Medicine....9
Daniel R. George, Ph.D., M.Sc.
The Cure..........................................................................18
Reeta Mani, M.D.
Faoud Ishmael Artwork...................................................20
Faoud Ishmael, M.D.
Passive vs. Active Performance:
Dramatization of the Yellow-Fever Epidemic....................23
Robert J. Bonk, Ph.D.
Spring Fever....................................................................26
Muriel Murch
Ritual .............................................................................31
Wynne Morrison, M.D., MBE
Punctuality for Doctors....................................................32
Alexander Mamourian, M.D.
A Drop of Blood...............................................................26
Muriel Murch
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
ii
Editor’s Column
Cheryl Dellasega, C.R.N.P., Ph.D.
Professor of Humanities at Penn State University
College of Medicine, Department of Humanities,
Professor of Women’s Studies at Penn State University,
500 University Drive, Hershey PA 17033-0850
[email protected]
Greetings, Readers:
You might be wondering: “Gosh, what ever happened to that journal called IJHH?”
It’s been one year since our last issue, and, like just about everyone else, the economic
context we find ourselves in has affected my ability to set aside the time I used to devote to
IJHH. Nonetheless, it remains one of my favorite academic activities and I’m committed to
continuing publication.
After some hard discussions and examination of past patterns, the decision has been
made to go to a yearly issue, continuing with the peer review process that makes IJHH
valuable as a scholarly journal focused on a variety of genres: research reports, articles on
educational approaches to the humanities, creative writing and commentary as well as
poetry, photography, and other forms of visual art that capture the interface between health
care and humanities. Since the first issue of IJHH we’ve been fortunate to continue to be
archived within the Paterno Library at http://publications.libraries.psu.edu/eresources/ijhh.
In this issue, two poems from health care providers are flanked by a discussion of why
poetry matters to both poets and readers. The Timeslips Creative Storytelling Project (http://
www.timeslips.org/) illustrates the power of narrative for both patients and providers—if you
ever have the opportunity to sit in on a session, I would encourage you to do so. Another
story about aging and the potential loss of “self” can occur follows that, but, like Timeslips,
offers a creative twist and hope for a meaningful existence in the later years.
Nontraditional approaches to medical and health education are mirrored in “Human
Bonds,” which describes encounters with different patients using varied media to further
illustrate the doctor-patient relationship and a research report on one professor’s creative
teaching strategies, which demonstrates the benefits of performance for students. Two
personal experiences with health problems and a final poem round out this issue, which
ends with dissertation abstracts as usual.
We love to hear from all of you with suggestions on how to do a better job of presenting
this important information so the humanities are kept in the health care equation. If you
have a book you would like reviewed, please forward it to me at the address above. As
always, your queries and submissions are welcome.
Warmly,
Cheryl Dellasega
Editor-In-Chief
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
1
Three Hours Later
Stacey Nigliazzo, R.N.
College Station, TX
ER
4am
Seven police cars
Social worker, forensic specialist, surgeon
All here for one patient
She remembers dancing at a club
Three hours later
Crowded trauma room
Surrounded by strangers
Blue uniforms, white coats
Prostrate on a stretcher
Metal stirrups, kick bucket
Operating room on standby
Arms hinged back with large bore IV lines
Saline bolus, two units of blood
Wants to scream
Blistering fire deep within her belly
Abhorrently familiar
Remembers the delivery of her infant son
Heinously worse
Hurried stitches and gauze packing
Buying time for the police
Forensic swabs
Bright flashes from a digital camera
Shredded clothing and bloody sheets
Red-stamped paper bags
Fingerprints and fluid samples
Re-constructing the alchemy of hate
Police officers thank me
Surgeons nod
Medically stable
My job is done
Stroking her hair, bid farewell
Noise from belted two-way radios
Scurrying OR staff wheel her away
Frightened eyes I hear them crying
Wondering what she heard mine say.
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
2
The Physician as Poet
Ronald E. Domen, M.D.
Professor of Pathology, Medicine, and Humanities
Penn State University College of Medicine, Milton S.
Hershey Medical Center, Hershey, PA 17033
Phone: (717) 531-5116 Fax: (717) 531-5536
email: [email protected]
An Everyday Clinic
Does not the ear test words
as the tongue tastes food?
- Job 12:11 (NIV)
Introduction
It is a well-known adage that all poets have day jobs because, other than a few exceptions,
one cannot make a living simply by writing poetry. One could argue that it is a good thing
that poets have meaningful employment other than making poems for the reason that poets
need to be involved with life in a real way, on a daily basis. For where do poems come
from, if not from everyday encounters with life? Such meaningful employment, Neal Bowers
contemplates, might provide the inspiration so that “poets might write once more with
individual distinction from the strongest urges of their hearts.”1
Medicine provides many everyday encounters with the “real” world, and physicians are
given privilege into the intimate details of many lives. Such intimacy as part of one’s dayto-day real job affords many stories not entrusted to most. For William Carlos Williams,
medicine “was [his] very food and drink [that] made it possible for [him] to write.” However,
such intimacy brings with it a responsibility for professionalism, confidentiality, and respect.
Physicians are taught to look, to examine, and to communicate in a cold, objective, and
detached manner. “This 54-year-old male was in his usual state of good health until two
days prior to admission…” This is partly out of respect for the patient, and partly to maintain
the proper emotional distance. And this is how it should be if physicians are to function as
professionals. But, when is it okay “to look feelingly,” as Edmund Pellegrino noted over two
decades ago? Why would physicians want to, and what role does poetry play?2
Pellegrino goes on to say that, “Medicine without compassion is mere technology, curing
without healing; literature without feeling is mere reporting, experience without meaning….
To look compassionately is the summit of artistry for both medicine and literature; to take
part in the struggle is the morality they share.”2 The postmodernist physician is in a daily
struggle for meaning, for “the morality,” for the ethic and the virtue, behind the opposing
forces of art and science in the practice of medicine. It has been observed, often in comic
relief, that young idealistic students enter medicine for humanistic reasons, only to have
the art beaten out of them and replaced with science and technology. It is only years later
that the aging physician may come full circle to the realization that what patients often
want, and need are not technological cures but compassionate and empathetic healing and
understanding.
Recent efforts have tried to keep the humanistic spirit alive and well as students progress
through medical school, through residency training, and on into practice. Narrative
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
3
medicine, the study of literature and the humanities in medical school, and the increased
focus on bioethics have become valued components in many medical schools.3,4 I will refer
to this effort as the “maintenance of humanism.” More specifically, by the maintenance of
humanism I mean those characteristics that not only connect us as human beings, such as
compassion, empathy, trust, integrity, altruism, and engaged communication – and that
form the profession’s ideals – but that are also continually held in the forefront as important
components of the physician-patient relationship.
The Importance of Poetry
Despite the contributions of some physician-poets over the centuries, and despite the
efforts of a few medical journals to publish poetry, I surmise that most of the “medicallyoriented” poetry being published today is being written by poets outside of the health care
profession, and that physicians are also not writing much poetry. There are a few exceptions,
of course, and this includes the few journals being published by hospitals or Colleges of
Medicine (e.g., Bellevue Hospital’s Bellevue Literary Review, Mount Sinai Hospital’s [Toronto]
Ars Medica, and Penn State University College of Medicine’s Wild Onions). In a recent article
in The New York Times it was noted that few contributions to the Bellevue Literary Review
are from physicians.5 In other words, patients and the friends and family of patients are
writing the poems. Why is this so? It may be that those physicians who write poetry are
less concerned about publishing their efforts for general readership. Or, and probably more
likely, if physicians want to tell a story they are more likely to write a narrative rather than
a poem.
I think poetry has come to be devalued and impoverished for several reasons. For
example, many people consider poetry as “soft-core babble” that is hard to understand.6
Others may feel that poetry lacks any significant substance or ideas.7 Or, some may feel that
narrative prose, rather than poetry, is a better way to “tell a story.” Others may feel that they
are not “sensitive” enough to write poetry. Still others may feel that they lack the skills to
write poetry.
The poet William Stafford does not feel that skill (in the literary sense) has much to do with
his ability to write poems.8 He feels that writers are “simply engaged” with the language.7
Stafford goes on to note that for “the person who follows with trust and forgiveness what
occurs to him,” then the possibility exists that a whole unseen human dimension will be
opened up.”8
Octavio Paz refers to poetry as “the other voice,” the “voice of passions and visions.”9
He says that all poets “hear the other voice” whether it is their own, someone else’s, or no
one’s. Paz goes on to point out that poets come from all walks of life and occupations, and a
random look at some of the memorable poets of the past century will confirm the presence
of businessmen, physicians, lawyers, diplomats, executives, and criminals. The important
thing is that they all listened inside of themselves for “the other voice.”
Sam Hamill, poet and publisher of poetry, says that “Language – and thus knowledge –
begins with listening…To listen is to know…and to see…First we listen. And then we name…
poetry is a commerce of the spirit.”10 Or, as another poet, Hayden Carruth said:“[The poem]
is authentic because I know the place and time I am writing about, and I know myself…
Intensity is what counts…intensity of perception, intensity of experience. To see, to hear,
to feel.”11 Isn’t this what physicians are trained to do – to listen, to see, to name? But, “to
look feelingly,” is typically not taught in medical schools and residency training programs.
Instead, students and residents are taught to think and see objectively, to put emphasis on
4
technologically-based diagnostic tools, and to place value on science-based curricula. Thus,
humanities courses are either not taught at all, or are given token consideration in a couple
of “ethics” classes.
How can poetry help us to listen, to see, to feel? Can poetry help us, help physicians,
to feel more compassion, more empathy, to be better listeners? Hamill goes on to say that
“The poem is a door leading to an interior landscape, it defines that which is in the heart
and mind, realizing the unity of one with the other.”10 In other words, the poem gives voice
to universal feelings and experience, and allows both the poet and the reader to achieve a
deeper level of learning and understanding that had been missing before the poem existed.
Poetry is illumination because the language is “at its most intense and potentially fulfilling.”12
Or, as the poet Denise Levertov said: “…the poem is a temple; epiphanies and communion
take place within it.”13
The assumption being made is that poetry can affect, and potentially alter, both the poet’s
and the reader’s insight into learning, knowing, and seeing – and ultimately – naming. Because
how we “name” the objects, the experiences, the illnesses, the patients, is all important. The
poet and the reader Anne Hunsaker Hawkins argues, reach a state of “epiphany” that leads
to increased knowledge and understanding, and to “a deep sense of meaning and value.”14,15
Through stimulation of one’s emotions, sensibilities, and imagination, poetry can work to
enhance one’s sense of compassion, empathy, and moral/ethical reasoning. By listening
to “the other voice,” the engagement with poetry, as Octavio Paz states: “…exercis[es] our
imagination, [and] teaches us to recognize differences and discover similarities…”9 Or, as
Abraham Verghese stated: “To hear the voice of the patient preserves our capacity to imagine
the suffering of the patient.”16
As physicians, we deal daily with epiphanic episodes in the lives of our patients. The
parents dealing with the death of a child, a patient with a newly discovered lump in
her breast, the mother with a stillborn baby, or the physician who made a diagnostic or
therapeutic error are epiphanies in the lives of our patients and colleagues. As Hawkins says:
“Whether the epiphany is a moment of inspiration, or a sudden new perspective on a
person or a situation, or a new sense of direction and purpose, or the terrible admission of
error, failure, and guilt, these are experiences that influence our decisions, shape our lives,
and deepen our interactions with others. They are crucial elements in the narrative of our
life experience. The ethic that ignores them is not only impoverished, but also unreal.”15
Making poetry out of these epiphanies, I believe, can only serve to ultimately make us better
physicians.
Toward an Ethic of Poetry
The Poet Carl Dennis and others have argued that poetry is decidedly ethical in nature
because of the relationship it demands between the poet and the reader.17,18 Unlike narrative
prose, poetry demands that the reader enter into a direct relationship with the speaker (i.e.,
the poet). As in discursive speech with another human being, where emotional engagement
is sought, the character of the poet (of the poem) is all-important if we are to be persuaded
or directed. Or, as Wayne Booth contemplates in The Company We Keep: An Ethics of Fiction,
we are interested in the ethical encounter of the storyteller (poet) with that of the reader or
listener, and what effect this encounter has on both the individual character and on society
as a whole.18 Physicians conduct their daily business, indeed all of us do, in stories. The
stories we tell each other have ethical value.
Wendell Berry has noted that poetry “concerns the values of the spirit” and “the moral
imperative” for the concern of poets to focus on the world (outward) rather than exclusively
5
on the self (inward).19 He goes on the say that storytelling has become estranged from poetry,
and that this “weakening of the narrative in poetry” is indicative of a lack of “responsible”
action.19 This responsibility of the narrative in poetry includes not only the aspects of
remembering and preserving the stories, but also, to seek, detail, and clarify truth and
responsible action. For Carl Dennis, the argument of the first-person poem, the poem
spoken as “I,” is an ethical argument with unlimited possibilities, and unlimited ways of
seeing and knowing.17 The virtuous poet, in Dennis’s view, must be able to show that he
cares about what he is saying in the poem and that it is true for him, that he has explored
various positions, and that there is a greater connection, or engagement, between the subject
of the poem and other aspects of life or actions.17 The poet who can balance these virtues in
his poetry can exhibit a freedom of expression, and a level of confidence and significance,
in the discovery of the universal about mankind. Wallace Stevens said that, “Poetry is the
imagination of life. A poem is a particular of life thought of for so long that one’s thought
has become an inseparable part of it or a particular of life so intensely felt that the feeling
has entered into it.”20 Poetry takes these seemingly disparate, random particulars of life and
seeks to unit the virtuous, universal aspects looking for the possibilities, the truth.
Poetry can serve the poet and the reader in contributing to a narrative ethic in medicine, to
illuminating the moral reasoning process, and serving to clarify responsible and professional
behavior (action).17,21 As the physician-poet William Carlos Williams noted about the
interaction of medicine and poetry: “…one occupation complements the other…they are
two parts of a whole.” And, “…the difficulty is to catch the evasive life of the thing [i.e.,
“some moving detail of life”]…[that] will yield a moment of insight.”22
A “moment of insight,” “the other voice,” “a commerce of the spirit,” an epiphany. Poetry
strives to lend voice to what is seen and felt, to name the inner vision, to form an ethic
as part of the maintenance of humanism. The poet identifies the circumstances and the
experiences, and then puts down the words that truly express a depth of feeling. “The words
are only the frame which focuses the epiphany we name poetry.”10
Casuistry is a case-comparison, or case-based approach used in bioethics to exemplify
or reach moral/ethical conclusions. Casuistry comes from a Latin word meaning “event,
occasion, occurrence.”23 In this regard, poetry can bring a casuistic approach to the physicianpatient relationship by bringing individual stories into a focused perspective and insight,
and by examining the particulars. This focused insight might be an attempt to address a
moral or ethical dilemma, or to attempt to make sense of suffering, or to celebrate a joyous
occasion. Poetry as casuistry implies that any particular situation can be approached and
examined in a unique way by applying the techniques of making a poem.
Personal Thoughts on Writing Poetry
I have never thought of myself as a physician-poet, but more as a physician who happens
to write and read poetry, or as a poet who also works as a physician. For some of the reasons
noted above writing poetry is a way to engage and connect with the world around me and at
the same time to plumb my own depths. In the process, I hope that I have made something
of value, and that I have achieved some level of enlightenment or insight either about myself
or about the things that are happening around me.
Carl Dennis states that, “The central experience of reading [and writing] a poem…is that
of making contact with a whole human being, not only with arguments and opinions but
with a complex of emotional, ethical, and aesthetic attitudes expressed with the kind of
directness and openness that we experience in the frank speech of a friend.”17 In writing
poetry, William Stafford says that he found himself taking “principled stands” in such areas
6
as religion, responsibility, peace, etc.; and, that his poems ended up being “respectful of
religion, people, and ideas that were different.”24
I do not feel that my work as a poet needs to be directed to, or necessarily intertwined
with, my work as a physician. I feel that the two vocations can be separate; thus I pursue
them independently. For me, poetry and medicine are related only so far as I am who I am
because I am a physician and because I write poetry, and in the same sense that I am also a
father, a husband, a spiritual being, a member of the community. Epiphanies can come from
anywhere, and can have universal meaning and insight applicable to my whole being – to
the maintenance of humanism. Thus, the fact that I am a physician sometimes finds its way
into my poetry.
As such, most of my poetry does not deal with medicine as its subject material or focus.
This was also true of William Carlos Williams whose narrative works dealt more with
medicine than his poems did. However, does writing (and reading) poetry, and especially
non-medical poetry, serve to make me a better physician? Can poetry help to make me
more compassionate, more empathetic, or a better listener in my contact with patients or
other human beings? I think poetry has the power to do these things. “To look feelingly” as
Pellegrino put it. Because poetry is a “commerce of the spirit”9 the particulars of seemingly
trivial human interactions must be responsibly examined and named. Thus, not only does
poetry help to make me a more compassionate and empathetic physician, but also a more
compassionate and empathetic member of the world at large – and, is there really any
difference?
Octavio Paz said: “Poetry exercis[es] our imagination, teaches us to recognize differences
and discover similarities…as creators of images and as images of their creations…If human
beings forget poetry, they will forget themselves.”9 Poetry allows us “to hear [or “sing”] the
voice” of the universal, of humanity, of life, and “preserves our capacity to imagine” the
depth and meaning of all that is around us. And, if we lose the ear to listen to “the other
voice” then we have lost something deep and profound for medicine, for ourselves, and for
humanity. My “other voice” compels me to write poetry. Not solely as a physician, but as a
physician who is also a poet. I close with a short poem that I wrote when a dear friend was
about to undergo surgery (“Natural History” originally appeared in the Grasslands Review,
Numbers 16 & 17, Winter/Summer, 1997. Used with permission).
Natural History
(for M.B.)
We walked through the Pharaoh’s tomb
brought to Chicago three thousand
years after masons cut the massive
stone blocks out of the earth.
Next to his two mummified children
we talked of the burden of being
part-time fathers and felt the weight
of disagreeable compromises.
In the Hall of Mammals we sat
on a wooden bench and spoke
about your upcoming surgery
and the relief it might bring while
the two man-eating lions of Tsavo
stuffed and posed glared
from glass enclosed natural splendor.
7
References
1. Bowers N. University poetry, Inc. Poetry 2002;180(4):221-228.
2. Pellegrino ED. To look feelingly – the affinities of medicine and literature. In, Peschel ER (editor).
Medicine and Literature. New York: Neale Watson Academic Publications, Inc., 1980:xv-xix.
3. Hunter KM, Charon R, Coulehan JL. The study of literature in medical education. Acad Med
1995;70:787-794.
4. Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA
2001;286:1897-1902.
5. Smith, D. A literary review at Bellevue? Believe it. The New York Times. October 2, 2002.
6. Sobel R, Elata G. The problems of seeing and saying in medicine and poetry. Perspectives Bio Med
2001;44(1):87-98.
7. Haines J. Living Off the Country: Essays on Poetry and Place. Ann Arbor: The University of
Michigan Press, 1981.
8. Stafford W. A way of writing. In, Hall D (editor). Claims for Poetry. Ann Arbor: The University
of Michigan Press, 1982:450-452.
9. Paz O. The Other Voice: Essays on Modern Poetry. New York: Harcourt Brace Jovanovich, 1990.
(translated from the Spanish by Helen Lane)
10. Hamill S. The Poet’s Work: The Other Side of Poetry. Seattle: Broken Moon Press, 1990.
11. Carruth H. Effluences from the Sacred Caves. Ann Arbor: The University of Michigan Press,
1983.
12. Stafford W. Interview: The Art of Poetry LXVIII. The Paris Review, No. 129, Winter 1993,
pages 51-79.
13. Levertov D. Origins of a poem. In, Hall D (editor). Claims for Poetry. Ann Arbor: University
of Michigan Press, 1982:254-264.
14. Hawkins AH. Literature, medical ethics, and “epiphanic knowledge.” J Clin Ethics 1994;5:283-290.
15. Hawkins AH. Medical ethics and the epiphanic dimension of narrative. In, Nelson HL (editor).
Stories and their Limits: Narrative Approaches to Bioethics. New York: Routledge, 1997:153-170.
16. Verghese A. The physician as storyteller. Ann Intern Med 2001;135:1012-1017.
17. Dennis C. Poetry as Persuasion. Athens, GA: The University of Georgia Press, 2001.
18. Booth WC. The Company We Keep: An Ethics of Fiction. Berkeley: University of California Press, 1988.
19. Berry W. The specialization of poetry. In, Gibbons R (editor). The Poet’s Work: 29 Poets on the
Origins and Practice of Their Art. Chicago: The University of Chicago Press, 1979:139-156.
20. Stevens W. The Necessary Angel: Essays on Reality and the Imagination. New York: Vintage Books,
1951.
21. Charon R, Banks JT, Connelly JE, Hawkins AH, Hunter KM, Jones AH, Montello M, Poirer S.
Literature and medicine: contributions to clinical practice. Ann Intern Med 1995;122:599-606.
22. Williams WC. The practice. In, Gibbons R (editor). The Poet’s Work: 29 Poets on the Origins and
Practice of Their Art. Chicago: The University of Chicago Press, 1979:196-202.
23. Jonsen AR. Casuistry. In, Reich WT (editor in chief), Encyclopedia of Bioethics. New York: Simon
& Schuster Macmillan, 1995:344-350.
24. Stafford W. You Must Revise Your Life. Ann Arbor: The University of Michigan Press, 1986.
8
A Door
Wynne Morrison, M.D., MBE
75 Harrowgate Drive, Cherry Hill, NJ 08003
phone: 856-267-5487
email: [email protected]
You were an explosion of youth and beauty,
high on a rock face in the rain,
glorying in the physical,
the joy of staying outdoors in a storm.
Your footing lost, a long slide down all is changed.
You are back to the beginning
having to learn everything,
this time with half your body pulled along.
Hospital beds grow cold at night.
Medical voices gather at the desk,
a pump beeps from down the hall,
busy crowds pass on the street below.
There are six years and a continent between us.
I bring you a small book,
faint purple flowers on the cover,
and many empty pages.
You take it, mutely nod, set it aside.
Through clear water I see you
drifting and powerless to swim,
my lifelines far too weak to pull you in.
Sometimes I catch a ripple on the surface,
but only when my head is turned away.
Authors comments:
This poem grew out of the experience of trying to connect with a patient
who has suffered a horrible trauma and is withdrawing into herself. It
reflects both on the patient’s experience within a changed world, and
on the physician’s feelings of powerlessness in witnessing the patient’s
struggle. It ends with the relationship not quite established, the patient
not quite settled.
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
9
Humanities in a Rapidly Aging World: The
TimeSlips™ Project at Penn State College of
Medicine
Daniel R. George, Ph.D., MSc
Assistant Professor, Department of Humanities, Penn
State College of Medicine
500 University Drive, Hershey, PA 17033
Phone: (717) 531-8778 Fax: (717) 531-3894
email: [email protected], Twitter:drdanielgeorge
Introduction
The landscape of Alzheimer’s disease (AD) is rapidly changing. For the past three decades,
hope has been consolidated in the potential for pharmacological compounds to intercede in
the neuronal death of age-related degenerative conditions such as AD. However, in the past
decade, over 20 anti-dementia compounds have failed in phase III trials (Dimond, 2010).
With scientists and the pharmaceutical industry rethinking models of causation in light of
these failed drug approaches (Whitehouse & George, 2011; D’Alton & George, 2011) and
retooling pharmaceutical strategies around earlier asymptomatic interventions (Rosenberg,
2011), there has been an increasing focus on non-pharmacological approaches in dementia
care that might mitigate cognitive and functional decline and improve quality of life for
persons with dementia. Interventions such as light therapy, nature-based therapies, cognitive
training, integrative medicine approaches, art and music-based therapies, intergenerational
activities and many other innovative approaches are being subjected to experimental studies
(Olazaran, Resiberg, Clare et al, 2010).
In the context of a rapidly aging developed and developing world (Ferri, Prince, & Brayne
2005), there is an emerging role for the medical humanities in creating and evaluating such
non-pharmacological interventions, many of which are informed by humanities disciplines
and difficult to subject to traditional RCT (Randomized Controlled Study) designs, leading
to outcomes that are more likely to be qualitative than clinical. This article examines one
specific non-pharmacological intervention that has emerged from the narrative medicine
movement within the humanities called TimeSlips™, a group-based creative storytelling
activity developed by a theater professor
in the 1990s and increasingly integrated
into dementia care settings worldwide
(Basting, 2009). The philosophy and
structure of TimeSlips™ is explained,
and the small but growing body of
research demonstrating its effectiveness
for persons with dementia and their
caregivers is reviewed. Subsequently, the
article describes the implementation of
TimeSlips™ by two classes of 4th-year
this perished heart
medical students at Penn State College of
Isle de las Gaviotas CommuMedicine (PSCOM) who participated in View the above video created by a student on
nicable Disease Hospital
a service-learning project at an assisted YouTube:
living facility off campus. Collaborative http://www.youtube.com/watch?v=BOxdpyB0g1I
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
10
narratives from the project are shared, along with other multi-media content created by
students based on the stories told to them by persons with dementia.
The power of narrative
Emergent in the last two decades, the field of narrative medicine has argued strongly
that stories, as culturally constructed expressions, are among the most universal means of
organizing and articulating subjective experience (Charon, 2001). From our earliest years
onwards, we learn through stories, and construct a meaningful reality by absorbing the
stories of others and creating our own narratives. Since most of our knowledge and thinking
is organized into narrative form, stories offer us the chief means of looking into the future,
predicting, and planning our lives and the lives of others, and reflecting on the past and
present (Turner, 1996). All humans have narrative brains that confer a species-wide ability to
be self-reflective and understand ourselves in narrative form over our life course (Chomsky,
1971; Laurel, 2004; McAdams, 1993). As the scholar Roland Barthes has argued, in every
age, in every place, in every society “narrative is present […] all classes, all human groups,
have their narratives […] narrative is international, transhistorical: it is simply there, like
life itself” (1975).
Because storytelling is so essential to the human experience — even for persons with
dementia whose cognitive and functional decline may compromise the ability to fully
engage in narrative — there has been a strong push to harness the power of stories in
eldercare environments, particularly in light of repeated drug failures. Previous research
on guided reminiscence programs has identified the benefits of narrative-based interaction
for the wellbeing of persons with dementia (see Tadaka & Kanagawa, 2007; Woods et al,
2005; Brooker & Duce, 2000). Further, a growing number of eldercare facilities have begun
making efforts to collect life-history narratives from each resident so that staff can incorporate
biographical knowledge into care planning and practice and see residents as persons with
meaningful histories rather than patients who are inexorably declining (Murphy et al, 1994).
By sensitizing staff to individual stories, it is believed that the workforce will be more acutely
aware of the idiosyncratic and contextual triggers that can impede or promote quality of
life for individual residents. A form of humanistic patient care called validation therapy
(Feil, 1982; 1993; Klerk-Rubin, 2007) has been developed to affirm the phenomenological
experiences of people with dementia by finding relevance and meaning in their narratives
rather than devaluing, ignoring, or reality-orienting them.
The TimeSlips™ storytelling project
Narrative in the form of creative storytelling has also been used as a direct therapy for
persons with dementia, differing from reminiscence in that the focus is not just on recalling
specific biographical details but rather on inspiring imagination. As a graduate student in
the mid-1990s, Dr. Anne Basting, now a theater professor and director of the Center on
Age and Community at the University of Milwaukee-Wisconsin, developed an innovative
creative storytelling program called TimeSlips™, which is presently being used in caregiving
settings worldwide. Informed by Dr. Basting’s humanities background, TimeSlips™
involves organizing a circle of persons with dementia, providing each person with the
same visual prompt – generally a staged and surreal image with no recognizable subjects
– and encouraging storytellers to articulate what is happening. What frequently unfolds is
a whimsical stitching-together of spontaneous observations, witty comments, biographical
memories, and even garbled sounds into a meandering narrative that frequently unravels
into incoherence and absurd contradiction, but also often maintains some semblance of
11
internal logic and cohesiveness. A facilitator guides the story along to maintain a degree of
order, while others sit with participants and encourage them to make imaginative comments.
A scribe writes down every verbalized comment in prose poem form.
TimeSlips™ engages imagination rather than placing an onus on remembering (Basting,
2009). As mentioned above, unlike traditional reminiscence therapy, which encourages
persons with dementia to remember
in linear, chronological fashion (i.e.
“when did you meet the people in
this picture?”), TimeSlips™ invites
participants into the frenzy of collective
storytelling, comedy, and dramatic
performance while channeling this
energy into a semi-coherent narrative
structure. Participants commonly act
out the characters they create, sing songs
evoked during the story, and even dance
around the circle. Consequently, the
activity can be a great relief to persons with memory and language impairments who may
not always feel able to properly engage with others in a rational, and consistent way, but who
are still quite capable of feeling a sense of wholeness through emotional connection with
other people. Participants flash their wit, make insightful comments, and prompt laughter
within the group, bringing to the surface a reminder of their underlying humanity, as well as
their remaining generativity. (See sidebar on pages 12, 13, and 15 for examplars)
Evidence for efficacy
A growing evidence base is establishing that participation in TimeSlips™ can benefit both
persons with dementia and their professional caregivers. Individuals with dementia who
engaged in a six-week session of TimeSlips™ were found to experience greater positive affect
than those receiving a control intervention (Phillips, Reid-Arndt, & Pak, 2010). Facilities
that have integrated TimeSlips™ into their care services over a 10-week period were found to
have more frequent staff-resident interactions and social engagement, while also nurturing
more positive staff views of residents than in control facilities (Fritsch, Kwak, Grant,
2009). More recently, a pilot study undertaken by the author at PSCOM demonstrated
that participation in TimeSlips™ significantly improved medical student attitudes towards
persons with dementia (George, Stuckey, Dillon et al, 2011). The latter half of the article will
describe this experience in greater detail.
TimeSlips™ at Penn State College of Medicine
As part of their Medical Humanities curriculum, 4th-year medical students at PSCOM
must take one four-week Humanities elective after completing medical school coursework.
In 2010 and 2011, a course was offered called “Narratives of Aging: Creative Approaches
to Dementia Care” in which students at PSCOM participated in four 1.5-hour visits to a
local assisted living home where they joined 20 residents at a retirement community in
south-central Pennsylvania. All participants lived on the locked memory support unit.
The course required that all students participate in TimeSlips™ as part of the class servicelearning component. The principal investigator (PI), previously certified as a TimeSlips™
facilitator, conducted student training during classroom time. Students also attended an
educational session at the retirement community to learn how to optimally interact with
12
residents and what to do in the event of an emergency. The course provided students the
option of developing final creative projects based on the imaginative content that emerged
from TimeSlips™ sessions.
During the course, students in both classes made four visits to the retirement community,
and worked with approximately 20 elder residents with ADRD (Alzheimers Disease &
Related Disorders). In each session, students used five pictures and took turns serving as
facilitators, scribes, and storytellers with the residents. Facilitators prompted the residents
with questions about the imagined events taking place in the pictures, while storytellers sat
next to the residents, repeating the facilitator’s questions and offering encouragement. One
scribe in each group transcribed each verbalized response onto a pad of paper. At the end
of each story, the scribe would read the narrative aloud and query the group about what
they wished to title it. Caregivers and staff from the retirement community joined students
on each visit to minimize potential risk to students and to residents. The PI attended and
oversaw each session, which lasted approximately 90-minutes including a debriefing with
the course instructor. Several stories are shared in the appendix along with the photographic
prompts that inspired them.
Tellingly, during both years of the course, over two-thirds of the students found inspiration
in the stories their elder partners told and chose to adapt TimeSlips™ narratives into short
animated videos, songs, drawings, books, one-act plays, and short stories for final projects.
One student created a 2-minute stop-animation video based on one of the narratives she
co-facilitated at the assisted living home. The video was placed on YouTube and quickly
accrued several hundred unique views: http://www.youtube.com/watch?v=BOxdpyB0g1I. At the
end of each course, students presented their final projects to their storytelling partners at the
facility, with several donating their works to the residents.
Qualitative evaluation
During both school years, student narratives before and during the TimeSlips™ intervention
were posted to a common on-line document. Students were asked to respond to questions
about their level of comfort working with persons with dementia, their perceptions of
creativity of persons with dementia, and their perceptions of the caregiving environment at
the assisted living home. Each student completed a written open-ended evaluation of the
course, responding to the following questions: 1) Please evaluate your learning experience
in this course; 2) Which aspects of the course did you find most meaningful/useful?; 3)
Which aspects of the course did you find least meaningful/useful?; 4) Comment about the
course and components (strengths, weaknesses, suggestions)?; and 5) How will this course
in any way influence your future clinical work with older patients? Additionally, a one-hour,
semi-structured focus group interview was held after the completion of evaluations during
which time students were asked to reflect on whether they valued arts-based experience
and how it had contrasted with their previous medical education and affected their future
treatment of persons with dementia.
A single document was created with all qualitative data. An emergent coding scheme was
used to identify relevant themes within 10 single-spaced pages of pooled student narrative
data using a grounded theory approach (Glaser, 1992). The coding framework drew upon
previous studies on TimeSlips™ referenced above. Codes were manually grouped under
broader thematic categories based on perceived relationships (Corbin & Strauss, 2008;
Ziebland & McPherson, 2006). Themes were formally identified when at least ten codes
13
were present that related to a particular
theme. Confirmability was established
by discussion with a colleague from an
alternative disciplinary background in
public health sciences.
That’s a good idea if he shaves, let’s think about it…
The water looks awful dirty.
He needs to shave!
She is sitting on a slide and she doesn’t like him watching what she’s doing.
She’s got her arm like this and she will get a hold of him.
She’s got her hand on the oar.
He needs to shave!
He needs a new cap too.
He is looking at her like, “What’s the matter with you?”
She’s got good muscles. Muscles are bumps.
It’s his boat.
They just met.
She looks really young.
They just met because she is stealing his boat.
That’s why she has her fist up, “Leave me alone!”
Her name is Abigail. The guy’s name is Tim.
Tim really needs to shave. He should spend ½ hour on shaving.
I hope he takes a shower at the same time he shaves.
They are getting to know one another.
They are singing, “Getting to know you” to each other.
His job is breaking stones into small parts.
This could be a first date, and they are thinking of going swimming.
The guy is trying, but the girl is rejecting him.
He likes her muscle.
He likes her just the way she is.
They are going skinny-dipping!
They are fun people.
They are going to get married and start a family.
She will hit him if he doesn’t fix the boat.
She will take him in the back room.
They may go out on a date.
The white thing in the back is a rope.
They will get to know each other after this.
She is holding on to something heavy.
She is holding onto an oar.
She is saying, “Knock it off!”
The weather is cold and raining – they are shivering, burrrrrrr.
There is a bridge nearby.
They are smelling the wood and trees from the oar.
She might have scratched herself with the oar.
They are going to get together – after he shaves.
Results
As has been reported elsewhere
(George, Stuckey, Dillon & Whitehead,
2011), during the course in 2010,
three themes emerged from the student
evaluations, demonstrating an overall
positive attitude towards the course and
a shift in perspective toward persons
with ADRD: (1) Participation in the
TimeSlips™ sessions had surprising
results for students, (2) Creative
interactions with retirement community
residents had an impact on students
personally and could affect future
interactions with older patients, and (3)
Students appreciated the change of pace
in creative teaching methodology.
Data analysis of the 2011 student
responses is currently being developed
for publication. However, an initial
coding of the data demonstrated that
many of these students were also
surprised at the level of narrative
creativity participants with dementia
were capable of.
In their writing before visiting the
assisted living home, nearly all of the
students registered some degree of
discomfort in working with a geriatric
patient base. Emotions of fear and
discomfort tended to be expressed both
in relation to the perceived attributes of
persons with dementia, and in relation
to the lack of facility students perceived
themselves to possess with this patient
population. With regards to persons
with dementia, students spoke largely
of their fear of aggressive episodes and
disorientation. As one student wrote:
“What makes me uncomfortable/ fearful
is if during interactions with people
with dementia, they become angry or
14
aggressive. I am not comfortable dealing
with aggressive people to begin with,
and in patients who are disoriented,
their real fear may result in lashing out.”
Another student was concerned about
potential racism that residents might
harbor against minority students as a
result of older persons with dementia
not being able to filter their ingrained
Strider – Deep One, he’s Adorable
prejudices: “Even though I know well
enough not to be offended by possible
It’s a bird, it’s a plane, it’s superdog!
racist remarks I cannot honestly predict
It’s a little dog, looking for something to eat because what my reaction will be if me or any of
they always do.
my classmates were to be the target of
He’s going to hit another man
such remarks.”
He’s hiding, playing superman
However, in their written reflections
Dog with a coat on
during and after the TimeSlips™
He’s posing patiently, like little dogs are apt to do
sessions, the students marveled at the
He’s warming up
way their relationships with participants
The dog’s name is Cutie Snoopie, he’s also called evolved through storytelling, and revised
Strider
their earlier discomforts and anxieties.
Call him anything but late for dinner
While some acknowledged that a degree
He belongs to Mickey Mouse, he’s anybody’s who of discomfort still remained, many felt
wants him
that their initial concerns had not been
His name is also Daisy, he didn’t want the other guy so realized. As one student wrote upon the
he chose a new owner
conclusion of the partnership: “I felt
The owner is taking the picture, just let him go already!
like creativity increased as residents saw
He looks like he’s bored. Good grief not again!
that we were really open to any type of
When do we have some food? He thinks all humans answer and would include that in the
are crazy
story. Everyone was mostly in good
He doesn’t like wearing this thing around his neck – spirits and willing to contribute, so the
he wants to move a little bit
aggressiveness and anger that I feared
He’s being sent somewhere. He might be thinking was not displayed. None of the worries I
“where are we going?”
had previous to our first day manifested
He’s going to church. When are we going?
themselves.” Another student noted
He’s going to the attic, looking for something to eat
being surprised by the cognitively
He’s so little he was taken from his dog family at an complex directions the narratives
early age
assumed: “Some people definitely had
He has four family members
themes of some happy endings, or were
He will eat anything
stuck on particular ideas (shaving), but
He knows if he gets extra people, he’ll feel better.
overall the story was taken in directions
I never expected.”
Students
even
acknowledged
rediscovering a creative spark within themselves as a result of the storytelling partnership:
“I thought I had lost creativity throughout medical school but I am glad the last course
in medical school brought some of it back,” one wrote in reflecting on the final project
experience. Another stated that TimeSlips™ “helped me to get in touch with the human
spirit and challenged what we thought we knew about dementia. It will allow me to be
15
more empathetic to people with dementia
and to understand what people that
age go through.” Some expressed that
the solidarity nurtured by TimeSlips™
attenuated the reductionism that had
been inculcated through their medical
school training, which had a tendency to
guide their focus away from the narrative
of the patient. As one student wrote in a
final evaluation: “Our medical training is
more or less reductionist – kind of just
look at people as diagnoses: this is an
Alzheimer’s patient, a heart patient, or a
diabetes patient. It’s easy to forget that
this is a person who has lived a life and
all these experiences. All these sessions, it’s
reminded us of learning more about these
residents how these events of their lives
transform who they are and we should
take that to heart as physicians when we
Cowboy Circus Dreams
care for them.”
For most students, seeing greater
The man is shooting at something in the air. There
creativity and personhood in persons
must be another figure throwing items into the air
with dementia also resulted in greater
so he can shoot at them. He could be playing the
recognition that such patients can enjoy
trumpet. The man’s name is Joe and he is shootlife, and that much can be done to improve
ing discs. He hits them every time. It takes place
their lives despite what the frightening
out West in Utah. It is getting toward evening. He
label of ADRD and its attendant stigmas
is wearing jeans because he is a cowboy and he
might suggest. One student expressed in
has no other pants. This takes place at a ranch.
the focus group: “I think just seeing the
He has family out West, maybe in California. The
patients here it’s humanized them a lot
horse in the background belongs to him. He has a
more. It’s not that you’re gonna change into
this strange completely different person,
boy named Tommy. Joe is 90 years old, but he is
you’re just you and there will be good and
probably more like 40. He doesn’t work in a suit,
bad days and you can get through it, and
he wears trousers and a vest. He goes to the cirthere’s things out there to help. So it’s not
cus to make money. He eats whatever he is given,
just slapping a label on a person; you’re
but eats lots of steak. He dreams of the outdoors,
trying to help them through and also
cowboy dreams. He isn’t home much. He must not
break through their preconceptions of the
have a wife because she wouldn’t put up with how
disease.” Again, this experience differed
he is dressed. His family wishes that they could
from conventional medical school training
see him more often.
in that it challenged more monolithic
biomedical views of the illness. As one
student wrote:
“Something else we learned about that maybe we didn’t get on our rotations is that
ADRD is not one diagnosis it’s many different diagnoses and encompasses many different
people who are not all going to follow the same path. Every person is different. So just
16
by saying you have AD that shouldn’t mean that label means you are the same as other
people and will follow the same path, or, as the media says, you’ll turn into the same
“‘shell’” of a person. That’s not what AD is, and I think each of us will take that away
from this part of our education.”
Nearly all students felt that this recognition would invariably improve their approach
to clinical care. As one student explained: “You want to reduce the stigma and also stress
[to family] that people are not gone; they can still be creative and have imaginations.”
Another student expressed:
“We should focus on what people still have and what makes them unique as
individuals. Are you going to be the same?—No, but you can accept the limitations
but also recognize the unique personality traits and creative and everything that’s still
there instead of regarding it as a disease you always have to fight. It can be a natural
progression or a change in lifestyle. It isn’t something anybody would choose of their
own free will, but we don’t have to say you have AD there’s no hope for you now. And
a lot of people when you get that label they treat you like a 3-year old child or talk to
the family member in the room instead of you. So – and I don’t like clichés – but you
just recognize that you can meet people with AD in the moment. When they are right
there with you there is still an interaction that can take place with you and the patient.”
Conclusion
Ultimately, the non-pharmacological, narrative intervention of TimeSlips™ has succeeded
not only in improving quality of life for persons with dementia, but also in humanizing
this patient base for a group of future healers who will be practicing in a world increasingly
populated by those affected by dementia. With ADRD drug development facing mounting
challenges in finding compounds to reverse or slow the complex, age-related processes of
neurodegeneration, there is increasing need to consider the value of non-pharmacological
approaches that can benefit those affected by dementia right now. The success observed in
TimeSlips™ – which has generated measurable benefits for persons with dementia and also
their caregivers – provides a strong argument for increased funding and research on a range
of non-pharmacological therapies informed by the humanities. Such interventions may be
more complicated to evaluate, but there is a clear role for the humanities in undertaking
these multifaceted investigations.
While an activity such as TimeSlips™ may not regenerate damaged neurons or clear
plaques and tangles from the brain, it succeeds in building solidarity through a shared
creative act while fostering respect and honor for the humanity of persons with dementia in
ways our society rarely does. Further, it puts an emphasis on the strengths and competencies
persons with dementia are still in possession of, and can reverse the loss of control many
feel while also conferring a sense of purpose and usefulness. Lastly, narrative-based activities
such as TimeSlips™ provide opportunities for relationships to form and deepen between
persons with memory challenges and those who will be caring for them in the present and
future. Such creative approaches to dementia-care, and such sources of hope, are desperately
needed in our rapidly aging world.
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237-272.
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Hopkins University Press.
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Brooker, D. Duce, L. (2000). Well-being and activity in dementia: A comparison of group reminiscence
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24/7/365 International Journal for Healthcare & Humanities | Volume 4 | Number 4 | Fall 2009
© Penn State University Department of Humanities
18
Spring Fever
Muriel Murch
Blue Heron Productions
77 Bolinas-Olema Road, Bolinas, CA 94924
email: [email protected]
For over two weeks now female gray-haired relatives--daughters, daughters-in-law,
granddaughters and nieces have been stepping off the elevators carrying bunches of bright
yellow daffodils. There, Gwendolyn knew she was right. It was spring again. She could always
tell. She loved the scent of new beginnings that she caught in small snatches as the flowers
dripped their gooey sap onto table tops before being captured in vases where they withered
and died in two, maybe three, days. The fresh air that also accompanied the nurses into the
building hung on their uniforms like dew drop fairies and she could breathe in the fragrance
as it lingered through the first of their shift’s rounds. Their uniforms did not feel cold as in
winter, or smell fetid as in summer, but were fresh as in new, and hopeful, and willing.
Gwendolyn had been 90 when she broke her hip and then suffered her first heart attack in
the hospital. Afterwards she had been brought up to the twenty-first floor from her apartment
on the third floor of the Willow Ridge Retirement Home for Seniors.
She remembered the fall. Her son Jonathan had been visiting, unburdening himself as a
schoolboy drops his backpack on the kitchen table coming home from school, about some
unsettling business that he always brought her. If he had found a wife he could have shared
his problems with her. But he had never quite had enough courage to overcome his fear of
rejection by even the mildest and sweetest of women, and he had never dared approach any
other kind to make that leap into intimate companionship.
Most mothers would be glad, she supposed. She had never been that maternal and, though
she had loved him the most of her children, she was a little disappointed in him. He could
have got on with his life and made something more of himself than owning a furniture store.
Admittedly it was his own store, not a franchise, but though she had tried she have never
become excited by his work or his world and found it, and him, rather dull.
But here she still was. Can’t have been too much wrong she thought with satisfaction.
Between the crossword puzzle solving minds of her doctors and the seemingly endless variety
of medications they prescribed, her heart kept its own discreet rhythm. Some days all she felt
was tired; other days, not. Her mind kept on working but the energy needed to gather and
share her thoughts often seemed more than she could spare. Her hip had not set well.
She was now bed and wheelchair-bound and that is what kept her up on the twenty-first
floor, the dying floor. You weren’t supposed to call it that but everyone knew. When you
came up here from downstairs your absence was missed by your friends who met for lunch
in the dining hall. They inquired after you for a week at the most. Maybe even a few brave,
staunch friends came up to see you, but nobody could stomach it for too long. The beds that
were made with hospital linens, not your own, and the half-filled urine bags that hung down
from them spoke of another intrusion into the body. The visibility, through always opened
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
19
doorways, of a friend’s barely covered nakedness, was all too stark a reminder of the possible
future.
Everybody knew that this could be their last home. If they were lucky they would die in
the bed they moved into, but the chances of that were not high. Nor, truth be told, were the
odds much better for dying in the building. You had to be quick about this dying business.
Gwendolyn had seen it time and time again. Someone came up here sick, got a little better,
sometimes even got to go back to their apartment for a while, but others were not so lucky
and lacked the strength or desire to return to life’s circus. If the nurses caught them at it,
slipping out of bed, to the floor or an unknown realm of consciousness, then off they were
sent to the hospital across town and with luck, for the staff, died, having had everything done
to keep them alive, over there.
After three months the nurses got used to the fact that Gwendolyn would not get well
enough to go back to her apartment, and accepted her as one of the long-timers. In the
mornings they bathed and changed her, got her up into her wheelchair, chatted about
breakfast that had been and lunch that was to follow. But they rarely spoke of anything that
occurred outside of the ward, either past or present.
Gwendolyn’s son Jonathan had been relieved when his mother decided to sell her small
home in Baltimore and move to the Willow Ridge Apartments Retirement Home for Seniors
in Philadelphia. Willow Ridge was about an hour’s drive from where he lived alone in the city
and he had been able to visit his mother regularly, twice a week, for the last fifteen years. But
when Gwendolyn had taken her fall and had her ‘turn’ as she called it, he had not expected
her to recover. As he was unmarried and the geographically closest of her children he had
assumed the main responsibility for her care.
He phoned his two sisters regularly and they took turns coming to visit at least once a
month. One lived in Southern California, the other in Arizona. Both sisters had raised young
families and though they now had more time to pay attention to their mother, they were
happy to leave the primary responsibility to their brother who, they both thought, deserved
it. As children they knew he had been her favorite, so now he could at least do this for all of
them. Gwendolyn was seen by physical and occupational therapists twice a week, but they
merely filled up the hours of the day rather than engaged her or improved the health of her
body or her mind.
Gwendolyn’s husband had died of overwork and sadness in his early sixties. She had
cared for him tenderly as loyal wives do and she had not remarried. Too old by those days’
standards and realizing that time was now finite, she did not wish to care for those men
who came calling, shopping, with pensions and money plans to bargain, sniffing her out
as a good caretaker for their last years. She was not lonely. She had been lonely enough in
her marriage and now relished a solitude that was free of any matrimonial or maternal guilt
After her husband’s death she allowed herself the extravagance of adding annual flowers to
her small sensible suburban garden and to pursue a mediocre golf game, enjoying the female
companionship it afforded her. Now, at 92, she was thankful for the strength that those
pursuits had given her mind and her wrists.
But Gwendolyn’s bones and muscles were too fragile to bear her weight and when she had
been given a wheelchair she quickly learned how to use it. She had made that adjustment
more easily that either she, her children, or the staff could have expected and was soon able to
move around the nursing unit with surprising agility for someone of her age. She needed help
getting in and out of the chair but that all came under the nurses’ care plan for her well-being,
“Gwendolyn bathed, dressed and up in her wheelchair,” was in her daily notes. She was
such a fixture, in fact, that she had become an easy patient, or “client” as patients were now
20
called under the more modern economically efficient care manuals. She was often assigned
to young student nurses when they rotated through the unit as part of their outside practical
experience.
Under the gentle guidance of Viola, the nursing aide who had cared for Gwendolyn as long
at they had both been on the twenty-first floor, these young nurses approached Gwendolyn
cautiously. Her stick-thin frame and apple ancient face made them tentative. Most of them
had not yet a familiarity with the physicality of aging. They reached out to touch her gently as
if she were an antique porcelain vase that they might break if they were clumsy. But she would
look up at them, her gummy lips quivering around her now oversized loose false teeth, and
smile, letting them wash and hold her. Often they would ask, in the condescending, nervous
voice of the young who instinctively know that they have no right to such presumption,
“Would you like to wear your pink or your yellow blouse today?” Gwendolyn would point at
one or the other; truth was, she didn’t give a toss just as long as they would get her up, and
dressed, and in her chair.
It was the early arrival of daffodils that seemed to transfuse their oxygen into her blood
so that desire rose in her like the sap of an old tree, urging her to go downstairs and sit in
her chair on the steps of Willow Ridge looking out across the man-made city lake and just
one more time greet this season of birth. She would continue this vigil in the hallway during
the long hot summer months even when the air-conditioning sucked out the sweet smell of
putrid body waste. But as summer faded into autumn and the days shrank to a low winter
light, her body would feel the changes. Her bones ached more and told her that it was no
use. For the winter months she would remain fairly quiet and compliant as the nurses wrote
with relief in their notes: “Gwendolyn up in her chair today. She sat quietly in the corridor.”
When the weather was storming outside she did not even wheel herself down the corridor
to the elevator. The smell of wet raincoats depressed her and reminded her somehow of her
married life, working and walking home from the bus stop laden with grocery bags that
disintegrated in the rain.
But in springtime she returned in her wheelchair to the open hallway between the elevator
and the nurses station to breath in the freshness from the nurses and visitors as they came
in from downstairs. Slowly the smells of the outside world built up in Gwendolyn’s memory.
Her mind collected in its own vase all the spring fragrances of the bouquets brought in until
by Easter time she could stand it no more. On these days she would wheel herself down the
corridor to the elevator doors and sit there.
“Good morning Gwendolyn, up early today?” The oncoming nurses might smile at her
but sigh inwardly knowing that with Gwendolyn up and in position so early, this might be
a difficult day.
When the elevator doors opened and a new visitor stepped out Gwendolyn edged closer.
The unsuspecting visitor would smile, admiring the determined little old lady’s independence,
and perhaps hold the doors open for her. One of the nurses would look up from the station,
strategically placed close by the elevators, and with a patient, thin smile, grab the back of the
wheelchair.
“Where do you think you’re off to Gwendolyn?” they’d say, and then pull the chair back
into the hallway to let the embarrassed visitor make an escape down the corridor, to their
loved one who had ended up on this floor. It can’t be that bad, they might think to themselves
as they hurried away.
Gwendolyn never answered the nurse’s query. Everything but her room, number two
thousand and thirty three, and the corridor, were denied her. She sat silently in her chair,
a hand maybe now raised to her chin or both hands folded in her lap, submissive as they
21
placed her further away from the elevator. She would spend an hour or so sitting in the chair
each morning and then take herself back down the hallway to her room to wait for lunch at
noon.
The amount on her tray for each meal was more than she had ever eaten or served to
anyone in her years as a housewife. She picked through the food carefully, having long ago
given up any guilt about the waste that might feed the starving in China or Africa or wherever
people were starving today.
That morning, Viola came into her room smelling of the jasmine that she brushed against
on her daily walk to work. Viola was small and dark-skinned with gray straightened hair, a
sweet smile and a limp that somehow signaled a wordless understanding of the Gwendolyns
of this world and her place beside them. She recognized the determination in the whiskered
chin that Gwendolyn thrust forward and upward to ward off the world even as she was being
dressed to enter it.
Gwendolyn was happy to see Viola pull out her mauve sparkly sweater with the threequarter length sleeves. When Gwendolyn was all ready for the day, Viola pushed the chair
into the corridor, past the utility rooms, onward towards the nurses station. She was up
early this morning and no one was at the desk. All the nurses were with patients or hovering
around the one or two doctors who came with a hurried efficiency to the floor. Gwendolyn
positioned herself in the empty corridor and waited, watching the visitors and staff coming
and going. She stayed there through the morning, returning to her room for lunch.
During lunch, rain began to fall. She could see it out of her window. It was a soft spring
rain. When she woke up from her nap, she looked across her bed out of the window, and
saw that the rain had stopped. There were clouds in the sky, yet the sun was shining sharply
as if examining the blue canvas on which to paint a rainbow. The afternoon still seemed fresh
and to hold a lingering promise. Viola came back into the room and changed the diaper that
Gwendolyn wore all the time now before setting her in the wheelchair once more. Slowly
Gwendolyn wheeled herself down the corridor again and positioned herself in front of the
elevator to watch the new shift of staff coming on duty. Each nurse, as she got off the elevator
,eyed Gwendolyn warily. The change of shift was a busy time while both crews of nurses were
preoccupied with the shift report.
Today was especially busy. After 17 years at Willow Ridge, Viola was retiring. The nursing
supervisor had come down to make a speech. A handful of purple balloons were tied to
nursing charts and bobbed up and down uncertainly. A large square chocolate cake covered
in butterscotch cream had been brought in inscribed with “Goodbye and good luck Viola.
Thank you for everything. We will miss you.”
The party noise held Gwendolyn’s attention. She remembered parties of her own life,
celebrations of birthdays, daughters going to college, friends at work, marriages, and even
her husband’s funeral She sat alone by the elevator, lost in memory.
Because of Viola’s goodbye party the allotted half-hour for report had run on and both shifts
were getting restless. The supervisor had given her small speech but now she was ready to
go. The day shift was anxious to leave and the afternoon shift was ready to begin their work.
Susan, the head nurse, made a tentative gesture at clearing up the mess from the party
but, as she always had, she left the main body of work for Viola to do herself. Viola took
the leftover cake and carefully slipped it into a smaller box someone had found. She would
take it home for her sons who, though grown, still stopped by to graze out of her house.
Viola hardly thought about this final leaving. She had been thinking about it for over a year,
counting down the weeks and days, and she was ready. The pain in her arthritic hip had been
constantly with her now for five years. She limped from the nurses station to the locker room
22
and began putting her belongings into her bag: an extra pair of comfortable shoes, a hair
brush, never used toilet articles that a patient had given her as a Christmas gift. She threw
some old magazines into the waste bin in the locker room. The box with the remains of the
cake was tied up with the balloon ribbons. She walked out of the locker room and passed
the nurses station.
“Goodbye Viola. Come back and see us soon. Don’t forget us now” Susan called out as she
too began to gather her belongings. Viola smiled to herself.
“I surely will,” she said, and knew that she would never return.
She walked across the hall to the elevator doors. As she pushed the “Down” button she saw
that both elevators were busily delivering and unloading staff to and from other floors. She
turned back to see Gwendolyn sitting in the wheelchair, watching her.
“Goodbye Gwendolyn, you take care now.” Viola smiled at the old lady in the wheelchair,
who paid no attention to her but looked straight ahead at the elevator. Viola moved behind
the chair to smooth and absentmindedly straighten the old lady’s hair. On an impulse, Viola
bent down to give Gwendolyn a kiss.
Just then the elevator doors opened and two groups of visitors got out. They were laughing
and happy and young.
Gwendolyn stared straight into the now empty space. Viola also looked up into the opened
elevator whose fluorescent lights blinked from inside, beckoning like a fairground ride,
at them both. Out of a long buried instinctive remembrance of escape, Viola grasped the
handles of the wheelchair and pushed it into the elevator. Quickly and expertly she turned it
around to face the door, put on the brake, and pushed “Lobby.”
The doors closed. The elevator slid smoothly downwards, by this time of the day smelling
faintly of sweet pureed feces and baby powder. There was a stop at the seventh floor where
another tired attendant got on. She exchanged nods with Viola but said nothing. The elevator
reached the bottom floor and with a gentle swish the doors opened.
Three-hundred and fifty-pound Marvin looked up from his desk, saw the wheelchair
holding Gwendolyn, and sighed. He already had his hand on the phone to call upstairs before
he saw Viola pushing the chair out into the lobby. She had placed the box of leftover cake on
Gwendolyn’s lap and the five purple balloons bounced and bumped together in the whirling
breeze from the revolving doors.
“Good afternoon ladies. How are we doing today? Can I help you there?” Marvin raised his
huge body up out of his chair and with the surprising grace of the morbidly obese, slipped
past the wheelchair to the door and held it open. Viola deftly steered the chair down the ramp
of the arched entryway.
“Thank you, Marvin.”
“Is Jonathan not coming today then?” The question hung lightly on Marvin’s lips.
“We’ll be back later,” responded Viola and she turned the wheelchair to the left along the
pavement towards the lake that lay glistening before them. The air was fresh and a little cold.
Viola reached down to pull Gwendolyn’s sweater more closely around her frail body.
Gwendolyn looked straight ahead as they crossed the main road and reached the beds
of daffodils bobbing their yellow heads. The tulips blooms were just beginning to blush
crimson from the moss green of their leaves. The breeze shook pink cherry blossoms and
sprinkled them on the pathway. The ducks swam their broods toward and then away from
the new arrivals to the lake side path. The breeze rose and danced into a wind that whipped
the pathway dry from the rain. It blew the clouds away from the sun-spattered rainbow that
shone across the far end of the lake. Gwendolyn breathed the chilled air deeply into her old
lungs and smiled.
23
Authors comments:
Spring Fever came from visiting a friend in the place she elected to call home for the last 25 years
of her life. Within that complex she moved in safety, from being an active senior to her death. But
in visits to her I saw that not everyone was so lucky or so happy. Gwendolyn and Viola quickly rose
from imagination and memory. I found and loved them both instantly. The story unfolded as fast as
I could write it.
24
Human Bonds
Faoud Ishmael, M.D.
Pulmonary Medicine
Penn State Milton S. Hershey Medical Center
500 University Drive, Hershey, PA 17033
phone: (717) 531-0003 x285567
email: [email protected]
The artwork depicted represents my interpretation of some of my encounters with
patients throughout my clinical experience in medical school. The focus of this work is
humanistic interaction. The relationship between patients and their family in a variety of
settings and circumstances in the health care environment was examined. An assortment
of media was used to capture the mood and relate the experience in each piece. Please feel
free to share any thoughts, impressions, or feelings.
Mother’s Medicine
Media: Graphite.
Although health care workers often are the primary caregivers, this work reminds us
that healing starts with the family, and in this case with the mother’s care for a sick child.
24/7/365 International Journal for Healthcare & Humanities | Volume 5 | Number 5 | Summer/Fall 2010
© Penn State University Department of Humanities
25
Despair
Media: Watercolor.
Dealing with terminal illness is a difficult process for the family of patients. In this setting
a distraught family member is comforted by her sister.
26
Unitled
Media: Ink
The work shown represents
a couple that I encountered
on my psychiatry rotation.
Both were diagnosed with
borderline-personality
disorder, and together they
were very self-destructive.
However, both were
oblivious to the negative
effect that each had on the
other.
Healing Hands
Media: Pencil
The relation between a
physician and patient
is central to healing. A
doctor’s touch can have a
healing effect on patients
just by providing comfort
and sympathy.
27
Untitled
Media: Colored Pencil
This drawing is of a couple that just had a miscarriage. They sat alone and in silence
behind the hospital, where their loss and loneliness seemed to be enhanced by the massive
structure of the hospital in the background.
28
Embrace
Media: Inkblot
Death of a loved one is
eased by the support of
family. This piece shows an
embrace between a mother
and daughter after receiving
the news that a close family
member passed away.
Mother and Child
Media: Pastel
The bond between mother
and child is explored. Few
things in medicine are as
miraculous as observing
the birth of a child and the
mother’s love and caring for
the newborn.
29
Sunrise
Media: Pastels
This scene depicts a man with his two young children. His wife was gravely ill, yet hope
remains. The light that streams through the window bathing the children represents a new
day and new hope.
30
Passive vs. Active Performance:
Dramatization of the Yellow-Fever Epidemic
Robert J. Bonk, Ph.D.
Associate Professor of Professional Writing
Widener University, One University Place, Chester,
PA 19013
phone: (610) 499-4265
email: [email protected]
Abstract
Given the dual nature of medicine as both science and art, the medical humanities offer
pedagogical techniques through which premedical and medical education can be enhanced for
the benefit of students. Performance—whether passive for audiences or active for participants—
is one such technique that offers a glimpse into the medical humanities. Building on previous
work in this area, I conducted a research study comparing passive and active performance in an
undergraduate course. Non-Honors students in the passive-performance group watched films,
whereas Honors students in the active-performance group researched, wrote, and performed
an original play based on the diary of a physician during the yellow-fever epidemic at the
turn of the 19th century in Wilmington, Delaware. Participants in each class completed a
10-question survey before and after either intervention. The only result (change from pre- to
post-intervention) of statistical interest indicated that students in the active-performance group
ranked “acting on the stage” as more important for the medical humanities than did those in
the passive-performance group. These preliminary results suggest the value of performance as
a pedagogical technique in the medical humanities.
Background
Performance—whether active for participants or passive for audiences—offers a glimpse into
the medical humanities. Although full-scale dramatization may not be feasible in crowded
premedical or medical curricula, the scaled-down approach of readers’ theater involves reading
directly from scripts on a simplistic stage (Savitt, 2002). I used this technique during my
first offering of the undergraduate course “Humanities and Medicine” at Widener University.
Honors students responded positively to enacting the roles of doctors, nurses, patients, and
caregivers (Bonk, 2006). Building on this technique, this course’s next offering challenged the
students to research, write, and perform a play on the ethical ramifications of Edward Jenner’s
development of the smallpox vaccine. Again, the Honors students responded positively to
their more active performance (Bonk, 2008), as did members of the Pennsylvania Medical
Humanities Consortium (Bonk, 2007).
A complementary pedagogical technique for exploring the medical humanities is passive
performance, achieved through watching and discussing films on medical topics. These films
challenge students to associate scientific and humanistic aspects of medicine and health care.
Upper-level undergraduates in a separate “Values Seminar” with a health care theme responded
positively to such films (Bonk, 2009b), as did the international audience for a presentation on
this technique (Bonk, 2009a).
As for many novel pedagogical techniques, the investment of time and effort can be high for
students as well as the instructor. Certainly, passive performance places less emotional strain on
the students and requires less effort on the part of the instructor than does active performance.
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
13
31
Would the learning outcomes of passive vs. active performance be worth the investment on the
parts of students and the instructor? To answer this question, I conducted the current research
of the relative benefits of passive vs. active performance in the medical humanities.
Procedure
The purpose of this study was to explore the pedagogical value of performance for the
medical humanities, with a focus on passive vs. active techniques. For the spring 2010
semester, I offered parallel sections of “Humanities and Medicine” for non-Honors and Honors
students, respectively. Although both offerings introduced literature, history, and philosophy
of medicine, the Honors section added active performance through dramatization, whereas
the non-Honors section substituted film for passive performance. The Honors students used
primary historical research (i.e., a physician’s diary from c.1800, available to the students in an
electronic format). Participants in either section were full-time undergraduates.
Participants in each of the two classes completed a 10-question survey (see Appendix)
during Week 9 (pre-intervention) and Week 16 (post-intervention) of the semester: five
questions related to demographics and five to assessment of performance. Questions were
check-box items, multiple-choice selections, and Likert-like scales. Students completed the
surveys anonymously, although the last four digits of their student identification numbers
were recorded to align results across the two assessments. Otherwise, responses are to remain
fully anonymous. Moreover, no publications or presentations resulting from the study are to
violate this anonymity. Participation in the assessments remained fully voluntary, with students
signing informed consent forms as required under the Institutional Review Board of Widener
University (IRB #79-10).
Students in the non-Honors section (passive performance) watched and discussed three
films related to the medical humanities. In the Honors section (active performance), students
researched, wrote, and performed an original dramatization of a physician’s medical diary. This
diary recounted the fight of Dr. John Vaughn against yellow fever in Wilmington, Delaware,
at the turn of the 19th century. This class performed their play as part of Widener University’s
Student Project Day on 16 April 2010 (Week 14 of the semester); students in the non-Honors
section were encouraged to attend this performance for extra credit.
Regarding data collection, students participated in either passive or active performance
according to their class of enrollment, with the type of performance the independent variable.
Responses from the survey at the two timepoints were the dependent variables. Analyses were
structured to compare these two groups directly. To be included in tabulations and analyses,
students needed data for all questions at both time points; also excluded were any students
who declined participation at any point during the study.
Response frequencies were tabulated for demographic data (Questions 1-5). Given
their ordinal (ranked) nature, assessment data (Questions 6-10) were analyzed using the
nonparametric Mann-Whitney test for the comparison of two independent groups (Dowdy
& Wearden, 1991). Before being compared, data for these responses were transformed into
the change from pre-test (Week 9) to post-test (Week 16) using this formula: Change = Posttest – Pre-test.
Because of the exploratory nature of this research, statistical interest was declared at the
0.10 level (2-sided), rather than at the traditional 0.05 level for statistical significance. Data
were statistically analyzed with SPSS software (Version 17.0). Completed questionnaires and
consent forms are to be kept in a secure cabinet to ensure confidentiality of all records.
32
Findings
This study comprised two main groups: non-Honors students with passive performance,
and Honors students with active performance. Of 26 non-Honors and 8 Honors students in
these groups, usable data were obtained from 16 and 5, respectively (Table 1). Despite the
unbalanced sampling, demographics for the groups were similar (Table 1). Notable differences
included a greater number of upper-class students in the non-Honors class, as well as a higher
proportion of Honors students interested in healthcare careers. Other than in high school, no
students in either class indicated Table 1:
previous acting experience.
Demographic Comparison of non-Honors (Passive Performance)
Regarding assessment data
and Honors (Active Performance) Students
(Table 2), the only change of
statistical interest occurred for
Characteristic
Non-Honors
Honors
Students
Students
Question 8, which asked students
(Passive
(Active
to rank their level of agreement
Performance)
Performance)
Undergraduate Classification:
with the following statement:
Freshman
2
3
“Acting on the stage is important
Sophomore
5
1
for understanding the role of
Junior
6
1
Senior
3
0
medicine in society.” Note that
Major Field of Study:
students in the Honors group
Healthcare-Related
5
3
shifted toward greater agreement
Science Other than Healthcare
4
1
Humanities
1
0
with this statement than did those
Other
6
1
in the non-Honors group (p =
Career Interest:
0.079). Although this change was
Healthcare-Related
7
3
Not Healthcare-Related
9
2
not statistically significant at the
Type of Acting Experience:
typical level (0.05), the change
High School or College
4
3
from pre-test to post-test suggests
Community Theater
0
0
Professional Theater
0
0
that active performance in the
None
12
2
dramatization project influenced
these students. Moreover, Honors
students were more likely to disagree with the statement before the intervention than were nonHonors students, giving more credence to this tentative conclusion.
Worth consideration despite the lack of statistical interest are responses to Question 9 (Table 3),
which asked students to rank their level of agreement with the following statement: “Watching films
is important for understanding the role of medicine in society.” This question sought to identify
if passive performance would have as much, if any, effect on non-Honors students. Although
these students did show a trend in frequencies toward greater agreement with the statement, the
difference between Table 2:
the
two groups was not Change in Outcomes Assessment for Importance of Acting on the Stage (Question 8) *
statistically notable.
Non-Honors Students
Honors Students
Of course, this Statistical Parameter
(Passive Performance)
(Active Performance)
exploratory study
Pre-Test
Post-Test
Pre-Test
Post-Test
has acknowledged Mean
3.38
3.19
3.60
2.60
3
3
4
3
limitations, notably Median
3
3
4
3
the
unbalanced Mode
Range
2-5
2-4
2-4
2-3
group sizes and Frequency:
1 = Strongly Agree
0
0
0
0
the bias of Honors
2 = Agree
1
2
0
2
3 = Neutral
9
9
1
3
status. Moreover,
4 = Disagree
5
5
4
0
5 = Not Applicable
1
0
0
0
changes
shown
* U statistic = 20.00; p = 0.079
33
by
students
in Table 3:
either group may
Change in Outcomes Assessment for Importance of Watching Films (Question 9) *
have reflected the
Non-Honors Students
Honors Students
Hawthorne effect, i.e., Statistical
(Passive Performance)
(Active Performance)
response simply to Parameters
Pre-Test
Post-Test
Pre-Test
Post-Test
the extra attention of Mean
2.75
2.31
3.00
2.80
3.00
2.00
3.00
3.00
being in a study. Such Median
3
2
3
3
an effect, if present, Mode
Range
2–4
1-3
2-4
2-3
would be larger for Frequency:
1 = StronglyAgree
0
1
0
0
students in the active2 = Agree
5
9
1
1
performance group,
3 = Neutral
10
6
3
4
4 = Disagree
1
0
1
0
who had attention
5 = Not Applicable
0
0
0
0
from the week of * U statistic = 29.50; p = 0.326
rehearsals. The lack
of notable changes for any aspect of Question 10 regarding the importance of rehearsal and
similar activities, though, suggests that these students may not have been overly influenced by
this attention.
Although more definitive research is needed, these preliminary results indicate the value of
performance as a pedagogical technique in the medical humanities. Whether the more timeintensive approach of active performance is warranted over the less time-intensive approach of
passive performance remains a choice of the instructor. An additional consideration would be
the nature of the students; in this research, the Honors students may have been more amenable
to this type of intervention. Nonetheless, faculty in the medical humanities may wish to
consider novel pedagogical techniques like performance as one more means for enhancing the
education of their premedical and medical students. This exploratory study provides avenues
for design and assessment of such interventions in the future.
References
Bonk, R.J. (2006). “From Page to Stage: Exploring Medicine through the Humanities” within the chaired
session “Evolving Pedagogies of Humanities in Medical Education.” Society for Literature, Science, and the
Arts (SLSA) Annual Conference. New York. 9-12 Nov. 2006.
Bonk, R.J. (2007). “The Trial of Edward Jenner: Writing and Performing to Experience the Medical
Humanities.” Pennsylvania Medical Humanities Consortium Conference. Carlisle, PA. 23 May 2007.
Bonk, R.J. (2008). “The Trial of Edward Jenner: Performance as Pedagogy in the Medical Humanities.”
International Journal of the Humanities 1(1): 27-31.
Bonk, R.J. (2009a). “Connecting Modern Medicine with Medieval Humanism: Watching Christi Puiu’s
The Death of Mr. Lazarescu through the Lens of Dante Alighieri’s The Divine Comedy.” 15th International
Conference on Learning. Barcelona. 1-4 Jul. 2009.
Bonk, R.J. (2009b). “Connecting Modern Medicine with Medieval Humanism: Watching Cristi Puiu’s
The Death of Mr. Lazarescu through the Lens of Dante Alighieri’s The Divine Comedy.” International Journal
of Learning 16(4): 279-287.
Dowdy, S., and Wearden, S. (1991). Nonparametric Statistics: A Test Based on Ranks (Ch. 7). In: Statistics
for Research (2nd ed.). New York: John Wiley & Sons.
Savitt, T.L. (ed.). (2002). Medical readers’ theater: A guide and scripts. Iowa City: University of Iowa Press.
Acknowlegements
I am indebted to Dr. Ellen Strober, the physician who transcribed the diary on which the play
was based. Dr. Vaughn’s diary was made available by Mr. E. Richard McKinstry, director of the
Library of the Winterthur Museum in Greenville, Delaware. Special thanks are extended to Dr.
Lori Simons of Widener University for her advice on study design and data analysis.
34
Punctuality for Doctors
Alexander Mamourian, M.D.
Associate Professor of Radiology
Hospital of the University of Pennsylvania
Dulles 219, 3400 Spruce Street, Philadelphia, PA
phone: (215) 662-6865
email: [email protected]
They are everywhere in the city, but for no particular reason a discarded paper coffee cup
triggered an uncomfortable memory as I walked to work that summer day. I suppose it was
because it had those blue and white graphics unique to urban coffee cups and I had just
moved to Philadelphia from a small town in New Hampshire. There the coffee cups, like
many of the residents, are more demure. Together the early light and that cup reminded me
of another walk to the hospital over 30 years ago.
I was then a medical student and just starting my clinical rotations at a storied hospital
across town. On that morning, I had promised to deliver to one of my patients his morning
coffee. This was, of course, not a commonplace arrangement for me or any other student.
But this patient was special to me. He was an older man with bilateral lower leg amputations
that I attributed to a lifetime of hard living. At my hospital he was being treated for a
prolonged infection at a suture line and he had been assigned to a private room in the
infectious disease ward. There the halls were oddly quiet and scented with an unsettling
mix of disease and disinfectants. Entry required a commitment since visitors and physicians
alike had to put on a facemask and gown to enter a patient’s room and dedicated hand
scrubbing was enforced on both the way in and out. This approach created a profound
sense of isolation for these patients although that was, of course, the whole point.
I had achieved a kinship with this particular patient who seemed to me a modern
day pirate with his tattoos and artificial legs. The slower pace of medical care in that era
allowed me the time to listen to his sometimes outrageous but always entertaining stories
as I changed his dressings each day. One day he confided to me that had been craving a
good, hot cup of coffee. While he was not fastidious about appearance nor critical of his
unenviable situation in any other way, the cup of coffee that arrived on his breakfast tray
each day was just too cold and timid for his taste. Taking this obvious invitation, it seemed
a small enough thing for me to accommodate his simple request and I promised to be back
with hot coffee, oh yes with two packs of sugar and dash of cream, at 6 a.m. the following
day.
But that next morning I woke to the sight of a clock showing that very same time, 6 a.m..
I was angry that I had overslept my promised meeting and in a youthful attempt to stop
time with speed I rushed downstairs in disarray. I ordered two coffees at the counter of the
nearby diner and hurried, as much as I could with two cups of hot coffee, for the hospital
that was just a few blocks away. I took a deep breath as I arrived at the door to his room
at 6:30 a.m..
I was hoping that he had just awakened, but when I walked into his room wearing my
mask and gown I saw his expression. I felt the chill even in his overheated room since it
didn’t require much sensitivity to see the disappointment in both his eyes and shoulders.
He politely offered some words of thanks but after a minute or two of uncomfortable
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© Penn State University Department of Humanities
35
silence, I excused myself to make my morning rounds.
In that brief exchange early in my career I learned a lesson that I would revisit as a patient
many years later: time passes at different rates for the sick and well. I can imagine how my
patient passed those early morning hours anticipating his special coffee. Once the clock
showed 6 a.m., however, every minute after would count as 10. By the time I arrived,any
joy to be found in that hot beverage had gone.
It is as though the watches of patients and doctors run at completely different speeds.
For doctors, the hours of the day just disappear, but for their patients, who are often
struggling with pain or boredom, an hour can drag on forever. Some patients find pleasure
in this change of pace, enjoying their break from daily responsibilities, but for most it is
a struggle to get through each day and, even worse, night. It seems that there is some real
meaning to that word: patient.
I found myself on the wrong side of the hospital bed rail some years back when I spent
ten days in an intensive care unit. There, I experienced my own time readjustment. A full
on anti-lock, both feet on the brake pedal, panic stop from a life overfilled with family and
work responsibilities to immobile in bed, pinned down by arterial and venous access lines.
While visits from my family and friends made those days bearable, I felt a sense of dread at
the end of visiting hours. Sleep was not a possibility for me and I couldn’t read so I relied
on the ceiling mounted TV and “Seinfeld” to occupy my stray thoughts until midnight. The
next four hours were the most difficult. I rested in a half awake-half asleep state, staring
into the darkness filled with muted voices from nearby beds. During those long hours the
regular appearances of my own nurses were as close to visits from angels as I may ever
see. But by 4 a.m., I would find renewed hope knowing that the glow of dawn would
bring the first wave of neurosurgery fellow and residents to my room. I looked forward to
that interaction because I could just feel that they, like me, hoped that with the passing of
another night I would be better.
For the surgical house staff, our early morning interaction was just the start of another
long day on a timeline that stretched on for years. I would guess they did not suspect that
I had spent those early morning hours in silent anticipation of our meeting and they had
most likely spent those hours in a dead sleep. My visit was just one check-off on a long
list of things to do before 7 a.m.. But when they stood at the foot of my bed our clocks,
spinning at wildly different speeds, would synchronize for just a few moments as they
examined me for signs of progress before they disappeared into the dark hall.
There really is no way to bridge the time differences between the well and the sick and
this slower pace is beneficial for healing. Although our minds may have adapted to life in
the 21st century, our bodies have not changed much in the past ten thousand years and no
federal mandate makes a patient’s wounds heal any faster. But during the brief time when
the spinning watches of doctors and those of their patients show the same time, doctors
should strive to live in that moment and provide patients their full attention. And while a
hot cup of coffee is good, punctuality is an even better way for doctors to acknowledge the
empty hours patients spend waiting for them.
Authors Commments:
After 50 years, half of them working as a physician, I still learned a lot in my one week stay
in a neurosurgical ICU as a patient. Some years later I tried to capture the perception of time by
physicians and their patients in this essay.
36
The Cure
Reeta Mani, M.D.
Virologist
National Institute of Mental Health and Neurosciences (NIMHANS)
Bangalore 560029, India
email: [email protected]
• Nitrogen: 20-90%
• Hydrogen 0-50%
• Carbon dioxide: 10-30%
• Oxygen 0-10%
• Methane: 0-10%
No. I wasn’t sitting in a chemistry class. Nor was I teaching in one. I was scouring the
omniscient Internet for information I could not seek from anybody else. Even my usually
poker faced family doctor might blush if I asked him.
I did not know, until then, that the components of the flatus were such boringly normal
sounding gases. I had expected some obnoxious sounding ones. Like the glares I get when
I fire one.
It was not until a few months after I turned 50 that I realized I had a problem. It was
not when my husband began to sleep in the guest bedroom. I just thought he was growing
older and more spiritual. It was also not when my daughter began to shop for more airfresheners. The teenage spirit, I reckoned.
It was when Mala, my dear friend, severely allergic to the Mumbai pollution for the past
15 years that we travel to work together, began to love it. She insisted we switch off the AC
and keep the windows of our car open all through the journey lasting an hour or so, every
day. On one such hot and humid morning, when we were re-doing our almost non-existent
make-up on reaching the office, did the realization dawn upon me. Like a bolt from the
blue. The stark truth confronted me. I needed medical help.
But how do you go to a doctor and say it?
I mustered enough courage to tell him that I suffered from a “gas problem.”
He prescribed a drab list of drugs and potions, but I wasn’t sure he could comprehend
the seriousness of my problem.
His medication did not seem to help.
I continued to be heard. And smelled.
Sometimes it caught me unawares to eject with astonished fury. At other times I could
anticipate its stealthy arrival and even maneuver it to fizzle out with a whimper. Some times
it was a Big Bang without much sting; otherwise it was a warm silent killer.
I took it upon myself to find a cure for this obnoxious malady. The Internet was the new
doctor for my embarrassing woes.
I embarked on my mission by shunning all “flatulence inducing foods.” Beans of all
shapes, sizes and hues, cauliflower, broccoli, radish, cabbage, onions, garlic, potatoes, eggs,
beer, bread, corn, milk and carbonated beverages made it to the hit-list.
I also made up my mind to eat slowly and masticate the food thoroughly, though I wasn’t
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© Penn State University Department of Humanities
37
left with many options to chew on.
“EXERCISE” announced every Website! “It helps digestion and reduces flatulence.”
I adopted a vigorous workout schedule. Anything to cure myself of this painless, yet
agonizing misery, I said to myself.
I would learn later that my tormenting exercise schedule and the constipation resulting
from abstaining from most edible objects had taken their toll. My twice C-sectioned,
pendulous, weak abdomen gave way to a hernia.
As my anaesthesia wore off from an emergency surgery for a strangulated hernia, I woke
up groggily in the hospital bed to see my family around me, peering over me with concern.
As thin transparent tubes of intravenous fluids nourish me through the needle poked
into my veins; I felt hunger pangs. I asked the surgeon when I could begin to eat.
“When we are sure that your intestines are back to normal after the surgery” he said.
“How can I know they are back to normal?” I asked curiously.
“Of course, when you pass flatus,” he replied nonchalantly, and walked away.
Authors comments:
At the outset I would like to declare this piece as a work of fiction, lest I become an outcast after
its publication! A casual chat with a colleague recuperating from abdominal surgery provided the
impetus to write it. Visualizing myself as the victim in distress albeit a fictional character, helped
me relate to the sufferings. I continue to believe that poking fun at myself and having a good laugh
does diminish the magnitude of misery around me!
38
Ritual
Wynne Morrison, M.D., MBE
75 Harrowgate Drive, Cherry Hill, NJ 08003
phone: 856-267-5487
email: [email protected]
The chart’s collected, suction checked,
intravenous lines all flushed.
Pump batteries fully charged.
An oxygen tank laid gently
on its side at the end of the bed.
A nurse mutes the noises of the monitor,
anointing our waiting silence.
His family fidgets, unsure
when to say their goodbyes.
I run through every number
on the flow sheet - urine output
well controlled by medication,
a heart rate that doesn’t change.
Like that awful children’s game -picking out letters that may hang
a stick figure from the gallows.
The phone rings.
The first helicopter has arrived.
An anesthesia team appears,
it is time to walk him home.
His mother gives him one last kiss,
clutches my arm, stumbles away.
My last laying on of hands - a touch to his head,
powerless to save or stabilize.
Authors comments:
“Ritual” describes the routine series of events that occurs when preparing a
patient who has been declared brain dead for the trip to the operating room
for organ donation. In the midst of the routine, the heaviness of the situation
stays with the physician who feels the need to briefly acknowledge the life that
is passing with a touch, the second “ritual” of the title.
24/7/365 International Journal for Healthcare & Humanities | Volume 6 | Number 6 | Fall 2011
© Penn State University Department of Humanities
39
Representations of complementary and
alternative medicine for cancer in popular
Canadian print media
Weeks, Laura Christine.
Proquest Dissertations And Theses 2009.
Section 0026, Part 0496 218 pages; [Ph.D. dissertation].Canada: University of Calgary(Canada); 2009.
Publication Number: AAT NR51217
Abstract Summary
Background. The mass media are an integral part of the context in which cancer patients
make decisions about complementary and alternative medicine (CAM). The mass media
are a direct source of information for CAM treatment options, and reinforce popular beliefs
about what CAM is, and is not, and how and whether it might be appropriately used in
cancer care. Despite being an integral part of this context, little is known about what is
reported in the mass media about CAM use for cancer, or how it is reported.
Purpose. To examine how CAM use for cancer is represented in the mass media in order
to provide insight into the context in which cancer patients make decisions about CAM
use.
Methods. (1) A content analysis of popular Canadian newspaper and magazine articles;
(2) A scoping review of research on CAM and the mass media; and (3) A frame analysis of
popular Canadian magazine articles.
Results. Media coverage of CAM use for cancer is common in the Canadian print media,
but does not seem to comprehensively include information on the risks, benefits and costs
of CAM use. CAM is most commonly represented as an alternative to biomedical treatment
leading to a cancer cure, contrary to how most cancer patients use CAM, research evidence,
and the perspectives of health professionals. Overall, the controversial nature of CAM in
the context of cancer care is central to media representations. The controversy frame is
used to highlight fundamental differences between CAM and biomedicine and to question
the legitimacy of CAM use.
Conclusions. Media representations are a less than ideal information source for CAM
decision-making. While they can help address some information needs of cancer patients,
they do not present comprehensive information and they reinforce the controversial aspects
of CAM use. These analyses of media representations demonstrate that CAM decisions
occur in a controversial context, and there is a need to better support cancer patients as
they negotiate this controversy.
Recommendations are provided for decision support for cancer patients, related to the
use of media information.
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© Penn State University Department of Humanities
40
The effects of leadership and authority on
cross-boundary information sharing in response
to public health crises: A comparative study
between the United States and Jordan
Mulki, Fawzi H..
Proquest Dissertations And Theses 2009.
Section 0668, Part 0723 374 pages; [Ph.D. dissertation].United States -- New York: State University of
New York at Albany; 2009.
Publication Number: AAT 3372183.
Abstract Summary
Regardless of national context, cross-boundary information sharing is inevitably
entangled with issues of jurisdiction, leadership, and authority. This study answers the
question: “To what extent do officials in the United States and Jordan share key leadership
characteristics and how are officials’ uses of authority similar or different?”
This study adds an international context to existing research on leadership and authority
by comparatively investigating the roles of leadership and authority on cross-boundary
information sharing efforts in response to crises within the public health sector. The
data focuses on government officials’ response to the outbreak of the West Nile Virus in
the United States and a water pollution epidemic in Jordan. A purposive and snowball
sampling frame was employed in the collection of the data and a custom dictionary was
developed. Traditional quantitative analyses were performed including factor analyses, a
cluster analysis, and t-tests to uncover variations across the cases.
The analysis revealed officials in Jordan and the United States relied in a similar fashion
on bureaucratic and legal structures to address the crises. Officials in both countries
demonstrated similar preferences for channels of communication supporting verbal and
non-verbal cues; exhibited traits associated with a charismatic style of leadership; and
relied on a hybrid approach in overcoming the crises by combining formal and functional
authoritative structures, hierarchical and collaborative styles of leadership, and personal
and positional sources of power.
Numerous differences pertaining to attributes of leadership and the uses of authority
exhibited by officials in each country were found. There was a varying degree of reliance
on authoritative structures between the two cases, with officials in Jordan relying more
on formal structures of authority. While officials in Jordan exhibited a more traditional
command and control style of leadership, individuals responding to the West Nile Virus
more often exhibited collaborative relationships and decentralized responsibility. Finally,
officials in Jordan focused on accomplishing specific tasks, whereas individuals in the
United States focused primarily on ensuring good interpersonal relationships. This study
concludes with practical implications and possible avenues for future research.
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© Penn State University Department of Humanities
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24/7/365
International Journal of Healthcare
& Humanities
Seeking Submissions
The International Journal of Health Care & Humanities accepts original articles, papers presented
at scholarly conferences, essays, poetry, creative writing, and Letters to the Editor. Work
that examines the interface of healthcare and the humanities from a global perspective is
welcomed.
All submissions will be peer-reviewed as per standard practice, i.e. anonymously and with
pre-established criteria for fit with the journal. A decision to accept, reject, or request revisions
will be determined by reviewers. If you are interested in reviewing for the journal, please
submit your c.v. to the Editor. In particular, we seek artists who would be willing to review
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Manuscripts must be prepared in accordance with the style guidelines set forth by the
Publication Manual of the American Psychological Association, 5th edition. The journal
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or headings. Please include a cover letter with your submission that acknowledges your role
as creator of the work, along with signatures of any co-authors or co-contributors, and affirm
that this is original work with rights owned by the creator(s).
Author Guidelines
Any author involved in healthcare is welcome to submit work. We will accept original research,
literature reviews, program evaluations, and relevant creative work such as poetry that relates
to humanities and healthcare from a local or global perspective. Papers should be between
1000 and 2000 words in length, typed in Word, in APA (American Psychological Association)
format. Send via email to [email protected]. If hard copies are sent directly to the editor they
must be accompanied by a CD submission as well. All papers will be peer-reviewed in a timely
fashion.
Artist Guidelines
Photographs and original artwork will be considered for publication after peer review by a
jury of artists. All artwork including alternative media, paintings, sculpture, prints, drawings,
photographs, paper collage, assemblage, installation, digital manipulation, ceramics, and
fiber will be considered and should be submitted in a digital format. Please include an artist
statement along with your submission. Artists/photographers can send images on a CD or DVD
to: Humanities & Healthcare, c/o Cheryl Dellasega, Ph.D., Penn State College of Medicine,
Department of Humanities, H134, P.O. Box 850, Hershey, PA 17033-0850 or email digital
files (.jpg, .tiff, .eps, .pdf .psd or Word) to [email protected].
Please include all contact information with your submissions: name, address, phone, fax,
email address, title of work, medium, and artist statement.
To receive a complimentary copy of IJHH, email [email protected] or check the Department
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internationaljournal
24/7/365
International Journal of Healthcare
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International Journal of Healthcare & Humanities
Penn State University Department of Humanities ISSN: 1941-5613
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