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Literature to heal the divide
  1. G Bolton1
  1. 1Medicine and the Arts, Department of English, Kings College, London, Strand, London WC2R 2LS; g.bolton{at}sheffield.ac.uk
    1. Saul Miller2
    1. 2Belford Medical Practice, Croftfield, Belford, Northumberland NE70 7ER; saulmiller{at}doctors.org.uk
      1. Sonia Holmes3,
      2. Amanda Howe4
      1. 33428 Cove View Blvd. #706, Galveston, Texas 77554, USA; snholmes{at}utmb.edu
      2. 4School of Medicine, Health Policy & Practice, University of East Anglia, Norwich, Norfolk NR4 7TJ; amanda.howe{at}uea.ac.uk
        1. Heather Ashworth5,
        2. Gill Stillwell6,
        3. Ann Kelley7
        1. 5Boundervean, Camborne
        2. 6St Julia’s Hospice, Hayle
        3. 7Hawkes Point House, St Ives, Cornwall, TR26 2NY; AnnKelley{at}aol.com

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          Poetry and fiction clarify and illuminate the continuity of mind, body, and spirit, sometimes dissociated in medicine. They offer a rounded view of humanity, entering into hope, terror, passion, ideas, knowledge, skills, beliefs, situations, and events. TS Eliot commented that “in the seventeenth century a dissociation of sensibility set in, from which we have never recovered”.1

          Fiction and poetry can help heal the Cartesian divide.

          The freedom offered by literature to wander in and out of science, through the aesthetic, the esoteric, and into ethics, can widen a clinician reader or writer’s understanding, knowledge, and skills. The art and the social science of medicine, as well as the spiritual can be examined and reflected upon. For example, as Clare Connolly, a general practitioner, puts it:

          “Sometimes, in the midst of all the impressions which reading fiction allows, I begin to sense that what I read expresses a dilemma or difficulty I have wrestled with in my working life as a doctor. That it expresses the nuance and complexity more accurately than can ever be detailed in a list of skills or how those skills can be learned and tested. In Regeneration by Pat Barker, perhaps it is the layers of doubt, the exploration of unfounded psychological techniques with very distressed individuals and the essential loneliness within the intimacy of the consultation which speaks most clearly to me as a modern physician.”

          Fiction and poetry can also enable a grasp of experiences far from our own. Martin McShane, a general practitioner:

          “I spent my student elective in India, Srinagar 1981. Simon and I shared a cold concrete room in the house surgeon’s hostel while a Himalayan winter cut the city off from Western life. Isolated from all I was familiar with, I learnt the most essential things in life were warmth, food, and good company. Those three things made life entirely bearable and actually enjoyable. The luxury in life lay in books. I would, if asked, submit that books are the fourth essential of life. Books provide knowledge and escape, both of which I sought and found in Srinagar huddled under blankets, dressed in all my clothes for warmth, transported by a novel from that place. Food we found in other students’ homes or a teahouse with a stove around which we gathered to eat buttered toasted, currant bread and sip at tea. But it was Simon’s company, his bright and lively mind, that kept me going as we talked of books read, books to read, careers to be made and loves to be found.”

          “Books read, and books to read” are an entirely absorbing subject because the lives of others are discussed. Literature opens a window onto feelings, thoughts, ideas, and experinces other than the clinician’s own, thus extending their understanding and sensitivity.

          Reading is a voyage of discovery; so also is writing creatively. Something tangible is there which wasn’t before. One doctor, on a reflective practice writing course, said of the explorations enabled by writing: “things come out because the story lets them out”; another said: “I like poetry because I can’t make it do what I want. It has to do what it wants”. And another: “this writing enabled me to find what I had never lost but didn’t know was there”.

          The stories and poems below take the reader into depths of reflection and experience; we share the writers’ knowledge, and quest. Sonia Holmes’s story is, as she says, “an instructive encounter in which a student is psychologically, spiritually and ethically challenged”. Ann Kelley shows us the value of poetry writing to patients. Amanda Howe tells us she “is a keen reader of fiction, and has experimented with using reflective writing with undergraduates as a route to student centred learning”. She sometimes writes poems, “which are distillates of thinking, and come unexpectedly”. One of her poems shares her liberating experience of losing her ID card. Saul Miller Uses story to try to get closer to the ways his patients make sense of things:

          “I am sometimes conscious of the way in which, as a well meaning doctor, my diagnoses regarding events that have occurred in patients’ lives smother their own interpretations. In a way this is fine to do because it is part of my job to give (a very particular, Western medical) meaning to situations and events. Yet I am sure that at times I offer my interpretations as much (or perhaps more) for my benefit as for my patients’. I think I use diagnosis, or more specifically diagnostic certainty, as a form of personal defence, a way of helping to limit my emotional exposure to the distress inherent in my patients’ own (earlier) interpretations of events. In my short piece of prose I was trying to capture that sense of acute emotional uncertainty that often accompanies a medical event, the conflicting interpretations that are possible then, before the doctor becomes involved and can smother them all with diagnosis.”

          Terminal delusion

          He woke suddenly, feeling many bad things at once. Nausea, colic, chest ache, breathlessness, headache: too many symptoms to acknowledge then, in the disorientating darkness. He sat up and shivered, felt cold.

          Sitting up made no difference. What time was it? He fumbled about on the bedside table, knocked something over, couldn’t find his watch; cursed the fact he had never yet replaced the old clock that broke. His wife snored lightly on nearby. Trying to go quietly, he pulled back the covers and got out of bed.

          Feeling his way slowly round the end of the bed and towards the door, he could feel a great welling up within himself. Awful. Like a volcano deep within the earth trying to funnel itself up through his body. There was no way of knowing where it would find its release. Nor when. Too awful to last much longer, he thought to himself as, still trying not to wake his wife, he fumbled harder to reach the door, the hallway, the bathroom.

          Edging along like this in the pitch blackness of a cloudy winter night, he made it to the bedroom door and into the hallway. He turned and aimed in the direction of the bathroom, beginning to feel faint now, anxiety and fear mingling freely in his confused consciousness. Is this how it happens then? Am I dying? A muttering sound from behind: his wife sleepily asking “Are you alright?” Yes, yes, I’m just going to the bathroom. He said it almost automatically, too distracted to do otherwise. But she could sense the urgency of his fumbling in the dark; waking quickly, she got up.

          He had made it to the bathroom by the time she caught up with him, turning lights on as she came. She stopped in the doorway, momentarily blinded by the stark brightness, struck instantly by how old, how haggard he looked. He stopped too, in the middle of the floor, squinting and indecisive: he had made it, but now that he had he didn’t know what else to do. The eruption was coming, he was trying not to panic but really, he was going to die.

          And then it happened. A cough from so deep within himself it felt as though it really might have its origins in the earth deep below the bathroom floor. And it hurt like that. And it felt like giving birth. And he cupped his old man’s hands to catch it, all that came forth from his chest.

          He was stood over the sink by the time the coughing stopped, trying not to make a mess. His wife had moved forward and was standing beside, slightly behind, his stooped figure; her left arm gently encircled his back. She saw that he had much blood in his hands, that the sink looked grimy, that she needed to do more cleaning.

          He felt elated: he was not going to die. He felt much better, perhaps even better, he wondered, than he had felt for a while. And there in his hands, proud above the blood draining down through the gaps in his fingers, was a gleaming white orb. A small egg? An eyeball with no eye? A cancer whole and intact? “It’s the cancer”, he breathed, “I’ve coughed it all up”. Inspired by this idea, she gripped his back more tightly and then hurried off to find a jar, two dressing-gowns and two cups of coffee. Neither slept again that night.

          Unholy ghosts: a medical student’s stroll down death row

          I had seen my patients for the morning. I looked at my watch. Thirty minutes to spare . . . making good time for a change. Breakfast before rounds was appealing, so I made my way out of the prison hospital, toward the cafeteria. As the heavy iron gates rolled past me and closed with a resounding “bang”, my luck shifted. I saw my resident, Shawn, walking briskly toward me with anxious steps. I stopped and waited for him; then I turned around and tried to keep up with him as we entered the prison again.

          “We got two patients from last night. One patient is in the ICU; I’ll see him. Can you see this one?”

          “Sure,” I replied, giving up hope on a hot meal on that cold morning.

          “Yours is on 6C. He’s in liver failure. Something happened last night. His abdomen exploded or something. Check it out, will you?” Images of blood gushing like a geyser and bowel flying through the air greatly disturbed me. Yet I pretended to be fearless; indeed, I even pretended to be enthusiastic as I replied, “I’m all over it, Shawn.”

          When I arrived at the unit, I asked the nurse about our patient. She was tough, as the nurses in the Texas Department of Criminal Justice usually were. “Oh yeah, Becker’s back! This might be his last time.” She sounded almost thankful. I learned that he was faring poorly with end stage liver disease. He had had ascites, and his fluid filled peritoneum had decompressed through his abdominal wall overnight. However, he was stable and his abdomen was sutured closed by the night team. I glanced out of the nurses’ station to his room. The big number “4” pasted to his window taunted me. Level four was a designation for the worst offenders. I had to be accompanied by an officer into the room.

          I walked out to solicit the services of one of the deputies. He sauntered toward me, frowning. “Do you need to go in there?” He asked.

          “Yes.”

          “He’s gonna die.” I wondered from what divine well this seer derived his profound insight. I refrained from responding. I had insufficient information to discuss his prognosis, and I did not think it appropriate. The deputy fumbled with his keys, undaunted by my silence. He continued, “Do you know what he did?”

          “No. It doesn’t matter to me. It doesn’t change what I have to do in there or how I’m going to feel about it.” I was strict about remaining ignorant of the offences of my inmate patients and determined to not judge them. He unleashed a hearty laugh as he turned the key. Then he displayed concern. “Well, I’m telling you this because he’s not your run of the mill offender. He’s not a robber or druggie. He got on a boat and killed the three people on it. He’s on death row, so watch yourself!”

          I suppose I should have been fazed by this knowledge, but I was long desensitised. Those three he killed were among the dead in the news, the movies, the wars of our time. No, I lived in a death culture and I was well acculturated. Besides, Becker was a human being with sins like the rest of us; my only business was his liver disease.

          As I surveyed his room, indeed, no grotesque creatures pranced around his room. There weren’t demons jumping on his bed or creeping along the dusty floor. After trying to talk to Mr Becker for a while, I realized that the poor incapacitated soul thought that I was his Aunt Judy and that it was the summer of 1957. He was clearly not oriented; I guessed it was due to the encephalopathy of a failing liver.

          As I pulled up his white scrub top to listen to his lung fields, I shuddered at what I saw. Enter the demons. Dusky shadows suddenly flooded the room. In Prussian blue, about a square foot across Becker’s back, was the symbol I learned to fear the most. It was the symbol of hatred. It was the Star of David, distorted, with its two triangles pried open to form a new and tainted insigne. It was the Cross of Christ with each of its two crossbars bent at the ends, adulterated, defiled. Above this tattooed swastika, also painfully engraved in blue, were the bold block characters that spelled out, “WHITE PRIDE”. Across Becker’s left flank, the artist had gotten more creative. A dark-haired vamp with blood red lips, punishing eyes, and overflowing cleavage wielded a whip as she advanced in her fishnet stockings and tall shiny boots. On his right flank, Death menaced with a sickle in its bony hand, staring through sinister skull bones and bottomless orbits. The rest of his form was concealed in a cloak of blackness.

          I proceeded with my auscultation, now nervous. Had he been oriented, Becker might have had issues with me, a diminutive dark skinned woman with an ounce of power over him. I could have been one of his victims, if not of murder, of hatred. The temptation to fear him emerged; worse, the temptation to despise him followed. It was effortless to care for this man and to be the good human, arbitrarily. Yet once I was privy to his hidden values, my responsibility to him became onerous. His body displayed images that shrieked mankind’s darkness. Through his tattoos, the unholy ghosts that drive us to depravity and hatred came to life.

          That cold morning, with a stomach crying out to be satiated, I knew what I had to do. In medicine, we are tested by fire, to be the compassionate practitioner, to be the good human, to be empathic and to love all, irrespective of who our patients are. I knew what I had to do.

          This piece was written six months after my encounter with two inmate patients, during my senior year as a medical student. “Becker” is a composite of two real patients. The piece reflects my perception of the ironies inherent in prison medicine in Texas. My encounter with “Becker” was an upheaval of traditional power structures of Texas heritage—while these two inmates endorsed white supremacy ideologies, they were both incarcerated and under the control of non–white health care providers and deputies. Second, the death penalty is supported in Texas; “Becker” was on death row, yet our goal at a prison hospital is to preserve and uphold the value of life of persons others wish dead. In a rather tumultuous environment, one must hold tightly to the values of the medical profession and never lose sight of the “human” in every encounter. My interaction with these patients evoked ambivalence, fear, empathy, sympathy, and a realisation that even within infrastructures that sanction hatred, no soul escapes either the obligation to love or the need to be loved.

          Unexpected

          The lady in bed 43
 is Mrs B,
 a case for gynaecology

          he thinks “hysterectomy”,
 she feels anxiety,
 and I
 hear poetry

          the act is on the body
 but minds the soul behind

          and those who watch receive,
 imagine only
 that for which they are prepared

          use poems then
 as well as bodies
 in hope of learning,
 and searching for response

          Lost ID

          I have lost my identity
 it slipped away en route from the canteen
 and never came back

          the smart woman
 jacketed and plasticated
 is gone
 role, access, status
 all dissolved

          now id will out from ID
 no alternative
 but to be outside looking in
 wicked, giggling
 slipping into places unsolicited
 unofficial, marginalised

          how marvellous
 for just a little time
 to be absolutely no one

          Patients into poets

          The act of creating something that wasn’t there, but now is, because of what you, the writer, have thought about and written, is in essence the same for a person who has not thought seriously about making a poem, as it is for a poet. It’s a wonderful feeling. “I made this thing, this poem, that others—especially the people who love me, will admire, enjoy, cherish.” It’s like making a wonderful cake that is never going to disappear, that you can offer to people, and there will always be a slice left.

          And most of the people I have worked with in hospitals and hospices have had no previous experience of writing creatively. They write a poem out of their pain or their wish to express love, or thanks, or just to say goodbye. I help them find the words they need. Or rather, I show them how I do it, and give them permission to follow my example or to say things that maybe cannot be said in any other way.

          Gill Stillwell, whose poem is included, was delighted to create at a time when she was almost totally dependent for her every physical need. On the first occasion I worked with her at her bedside in the hospice, her husband arrived to visit her and she sent him away saying: “I’m too busy writing a poem—come back later”.

          He now has the poems that she wrote in those last, creative, weeks of her life, and they are a solace, a pleasure, and a matter of pride to her family.

          These poems came from the exercise of reading Edward Thomas’s And you, Helen and then using the first line or so, or a variation of it to enable the writers to give voice to their feelings. The writers were from Boundervean, a drop in centre for people with mental health problems, and from St Julia’s Hospice, Hayle.

          And you Blanche

          And you Blanche
 And you, Blanche, what should I give you?
 So many things I would give you—
 time to realise your dream,
 health and youth to carry on.
 Strength, to achieve your aims,
 and I would take away your pain.
     HEATHER ASHWORTH
     Boundervean, Camborne

          If I could

          If I could, I would give you time to potter
 with your plants, the scarlet geraniums, the deep
 purple, the delicate lobelias.
 I would give you time to walk with me along the cliffs
 to the cove—the gannets, the cormorants,
 the herring gulls calling us out to sea,
 where we watch the seals appear to the chug of the engine.
 If I could, I would give you more time to laugh with me—
 your gentle chuckle which fills me with love and warmth.
 Just to spend more time together, to feel your arms
 around me at the end of the day.
     GILL STILLWELL
     St Julia's Hospice, Hayle

          Anniversary

          I would give you time to squander with your tulip trees,
 your artichokes, courgettes and raspberries.
 Time to sit on the old black bench
 and gaze from Hawke’s Point across the long pale beach,
 time to watch the elms and macrocarpas bend
 framing the curve of Porthkidney sand—
 and more of what you already have,
 my unquestioning, undiminished love.
     ANN KELLEY
     Hawkes Point House, St Ives, Cornwall, TR26 2NY; AnnKelley@aol.com

          Saul Miller is a general practitioner in Northumberland; Sonia Holmes is now an Internal Medicine intern at University of Texas Medical Branch; Ann Kelley is a published poet/novelist, who teaches patients and health care professionals with the Royal Cornwall Hospitals Trust’s Department of Medical Education; Amanda Howe is Professor of Primary Care at the School of Medicine, Health Policy and Practice, University of East Anglia. Gillie Bolton is a writer and senior research fellow at Kings College London. Grateful thanks to the patients for giving written consent for publication.

          Reference

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          Footnotes

          • Opening the word hoard is edited by Gillie Bolton. Ideas and items should be sent to her at the address detailed.

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