COURSE CONTENT AND STRUCTURE

The course begins with the topic The body image in the education of health care professionals, moves on to Gender body image issues, and Inherited and acquired abnormalities of body image, then concludes with Images of mental illness” (see table 1). These topics are broken down into subtopics as outlined in subsequent tables. Before each meeting, students are responsible for reading assigned material. Class time is then devoted to lectures and discussions of the material and the viewing of appropriate art works. Each instructor is allotted a certain amount of time to present a topic in his or her area of expertise, although all instructors attend, and participate in, all in-class sessions. For the last three years, an additional activity has been small group breakout sessions during the final hour of each Friday session to give students the opportunity to talk about any questions they may have about class discussions or their essays. Students are also asked to share their writings and comments during this time. In addition, one class is devoted to a guided visit to the local art museum to view appropriate artistic images of the human body.

To initiate the first topic, Mary Winkler's article, “Seeing patients”,¹ attending particularly to her concept of there being “no innocent eye”, is introduced. Several artistic covers from issues of the Journal of the American Medical Association, such as the Alice Neal Don Perlis and Jonathan (1992) cover, the Alice Neal The Last Sickness (1993) cover and the Sir Roy Calne Child After a Liver Transplant (1992) cover are displayed.⁴ Students are then asked to write about these covers, for example, who the people are and what they can discern by looking at the art works. At the end of the class period, student writings are collected and responded to by faculty members. It is often possible to distinguish the medical and non-medical students from these writings through their responses since medical students tend to respond technically (for example, “the woman in the picture appears to be exhibiting signs of acute cardiac failure”) whereas non-medical students generally focus on the feelings evoked by the picture (for example, “the aged lady in the picture seems very sad”).

As outlined in table 2, the focus turns to the “body” as it is represented during the education of health care professionals after the introductory session.

For this purpose, several poems are introduced, such as: On Studying Anatomy,⁵ by Diane Roston, a medical student who muses about what a thirty-one-year-old caucasian female cadaver was like before she became a motorcycle accident victim; Two Views of a Cadaver Room,⁶ by Sylvia Plath, who compares the dissecting room to a Breughel painting; and The Autopsy Room,⁷ by Raymond Carver, which describes an emotional response to finding a “cadaver leg” while cleaning an autopsy room. The short story, The Moths⁸ by Viramontes describes how immediately after her death, Abuelita, the grandmother in the story, is placed in the tub and intimately scrubbed in a baptismal ritual style by her granddaughter. Many students have a difficult time with this scene since they are used to reading practical articles which approach topics in a realistic fashion. (For example Robert, in the 1994 course, responded in an essay that “[the granddaughter bathing her dead grandmother] is impractical; it's not something that would usually happen”.⁹)

The discussion of the short story Sarcophagus¹⁰ by Selzer is particularly useful in discussing how the body is viewed during surgery. One specific activity during this section involves the viewing of a slide of Rembrandt's famous painting, The Anatomy Lesson of Dr Nicolaas Tulp. Students are asked first to describe what they see and later to design questions which could elicit important information about the event depicted. This exercise is designed to encourage non-judgmental observation as well as to test students' ability to ask precise, insightful questions. The painting also educates students about the “public nature” of earlier dissections and the more “formal” body image of earlier physicians who in the painting wore black robes rather than white coats. Historic slides representing surgical operations are also shown and discussed.

Further to expand the art component, the faculty elected to include historical views of the body in the early Egyptian, Greek and Roman periods prior to dissection (which, together with classical anatomic drawings, is so much a part of the current anatomy teaching in modern medical schools). An effort is made to “personalise” the cadaver during this section of the course. Although a number of current medical schools hold cadaver ceremonies to pay respect to those who contribute to medical science education by donating their bodies, there is little follow-up training to expose students to historical, artistic and literary reflections on the human cadaver. The article by Wu³ was added recently to emphasise the value for one of the authors, an MD, of combining anatomic dissection with the artistic study of the living person to provide a more balanced clinical view of the body.

Medical illustration as an art form is also discussed during this section of the course. One interesting comparison used for illustration is that of Leonardo Da Vinci's anatomic drawings of the heart and the very important and useful Netter anatomical drawings. The painting by Frida Kahlo of The Two Fridas with their exposed hearts and the artwork of Andra Gera showing a Breaking New Ground heart are also compared, illustrating the many connotations of the universal symbol of the heart. For medical students it is particularly helpful to show the Netter slides in a different context to confirm for them that perception creates expectation.

During the Gender and body image section of the course, we use a plethora of art and literature (listed in table 3) to characterise the issues related to gender and body image. As a novel introduction, a slide of a cover from the New Yorker, caricaturing many of the famous female nudes [for example, Rousseau's, The Dream (1910), Leger's Three Women (1921), Picasso's Two Seated Women (1920) and Renoir's Young Girl Bathing (1892)] is shown to illustrate how different artists have represented the female nude body.

The most substantial literary work used during this section of the course is the collection of novellas, The Matisse Stories,¹¹ by A S Byatt, which contains the three short stories, Medusa's Ankles, The Chinese Lobster, and Art Work, all of which touch upon the gender and body image themes discussed during this section of the course. Medusa's Ankles focuses on a 40-year-old professor getting ready for a television interview who is reminiscent and saddened by her own “aging body.” It works well when this text is used in conjunction with Mary Winkler's article, “The Good Body”¹² and David Gilmore's article, “The Beauty of the Beast: Male Body Imagery in Anthropological Perspective”.¹³ What usually begins as a humorous discussion about male and female beauty contests evolves into a more serious conversation about extremely unrealistic female (for example, weight) and male (for example, “baldness” and “height”) body image expectations and the multicultural nature of gender norms. The Chinese Lobster, the story of Peggy, a suicidal, anorexic graduate student writing on Matisse, is discussed in juxtaposition with Everything that Falls Has Wings,¹⁴ by Katherine Parkman and Holy Anorexia: Anorexia Nervosa,¹⁵ by Saraf Manisha. Here is an excerpt from one powerful passage in The Chinese Lobster which describes Peggy's anorexic body.

Her skin is like a potato . . .her body a decaying potato . . .in [a] great bundle of smocks and vests and knitwear and penitential hangings . . .. [H]er arms are bandaged like mummies . . .swollen with strapping and string.¹⁶.

This story, where Peggy is completely isolated with her illness (as, for instance, a lobster in a display case), contrasts nicely with Parkman's story about a young girl who overcomes her illness with the aid of a caring boyfriend and physician. The third story, Art Work, about the Dennison family members who are struggling with shattered artistic dreams and gender role-playing issues, is discussed in conjunction with an in-depth lecture about “Matisse as Artist”, with appropriate accompanying slides.

To cover the subject of obesity, excerpts from several medical articles which describe the correlation between low self esteem, low socioeconomic status, level of health care and obesity issues are discussed along with the short story, The Fat Lady¹⁷ (as told in first person by psychiatrist Irvin Yalom) and the first chapter from Susan Bovey's book, Why Being Fat is Not a Sin.¹⁸ The frank admission by the psychiatrist in The Fat Lady of his prejudice against fat women and Bovey's honest reflections on how it feels to live in a fat female body make this session one of the most successful discussion periods. One example that demonstrates what students generally learn during this session is Nate's reflection in one of his journal essays, where he admits his own feelings, evoked through reading The Fat Lady. He writes:A friend asked me the other day after class if I treat very overweight patients any different than I treat other patients. My first instinct was to say no. But then I thought about it for a while and realized my attitude is different toward obese people because I assume they are lazy or don't try hard enough (to lose weight).¹⁹

Another student excerpt reflects how medical students come to reconceive the obese patient during this unit:I never realized until now that I had [prejudicial] feelings and could unconsciously be treating my obese patients any differently. However, after my reading, I realize that I too get annoyed when I have to check the blood pressure of a patient whose arm cannot fit into the small blood pressure cuff. I also probably haven't asked as many of them to disrobe for the physical exam and I know that I tend to attribute many of their medical problems to their weight.²⁰

To begin the subject of pregnancy, there is a lecture with slides of artwork entitled “The Enclosed Garden” to show that particularly in religious art the subject of pregnancy has been kept purposefully obscure. The art historian who gives the lecture discusses various art pieces—paintings, sculptures, etc, which show the madonna surrounded by a nimbus or in a walled garden or other closed space (part of the cult of Mary). The lecturer suggests that earlier views of pregnancy and motherhood seem to keep the madonna from public view or in a place for veneration, which is, of course, quite in contrast with more modern views of the pregnant woman. A review of Dea Trier Morch's novel, Winter's Child,²¹ which contains the author's excellent black and white illustrations of the pregnant body is presented to demonstrate the visual and textual experience of pregnancy and childbirth as seen through the eyes of a group of women who deal with their complicated pregnancies in a Danish maternity hospital. Michel Foucault's History of Sexuality ²² and the 1991 Vanity Fair cover of Demi Moore's pregnancy are then presented to precipitate dialogue about the taboos associated with the female pregnant body, particularly as it is perceived and interpreted by the viewing public.

The use of Egyptian, Greek, and Italian images (for example, Old Kingdom, Menkura and his Queen, ca 2500 BC, Spear Bearer, Polyclitus, 440 BC, and Venus Adoring Herself, Titian, 1530), followed by more modern depictions of men and women (for example, Edward Steichan's, J Pierpont Morgan, 1908 and Robert Mapplethorpe's, Larry and Bobby Kissing, 1979,) demonstrates the means by which cultural ideologies have created gender stereotypes. A local artist who sculpts bodies using body casts to venerate “the unique three-dimensional record of one person, frozen in time”, speaks with the students and shares pieces of his artwork and stories about his relationships with the subjects. The artist is frank with the students about how people he has worked with (for example, men with small penises, women who have experienced mastectomies, women who are pregnant) feel about their “less-than-ideal” body shapes. An instructor in photography presents modern (for example, William Strike) and postmodern (for example, Cindy Sherman, Robert Mapplethorpe) interpretations of the “eroticised” or even “fetishised” sexual body.

Since the third offering of the course (when there was an excellent local performance of the play), Tennessee Williams's Cat on a Hot Tin Roof ²³ has been incorporated into the course. Full of verbal and visual body images (for example, Brick, Big Daddy, Big Mama, Maggie the cat, the no neck monsters), the play nicely links student experiences with class topics. Video excerpts ^{24, 25} from different film versions of the play (for example, the 1968 version with Paul Newman and Elizabeth Taylor; the 1984 version with Jessica Lange and Tommy Lee Jones) are used also to emphasise the influence of time and culture on cinematic productions. Two specific examples which we talk about to illustrate the influence of cultural norms on media productions are the fact that not one television version shows “Big Mama” as an obese woman, and that only the most recent television production of the play has accurately depicted Brick's unresolved homosexual feelings toward his best friend, Skipper.

Presentations for the third unit on abnormalities of body image begin with examples of paintings of note showing dwarfs and other freaks of nature. (See table 4) In the past, parts of the controversial movie, Freaks,²⁶ 1932, were shown, but more recently, an excerpt from the film Twin Falls Idaho²⁷ (the fictitious story of Siamese twins) was used instead. Also employed during this section is the short story, Imelda²⁸ by Richard Selzer, the story of a plastic surgeon's touching encounter with a young Hispanic woman with a hare-lip and cleft palate. Hawthorne's classic, The Birthmark,²⁹ is discussed as well, often provoking discussion of the dangers and limits of using science to tinker with human imperfections.

In addition to watching part of the movie The Elephant Man,³⁰ we assign the very sensitive and accurate descriptions of this unfortunate man written by Dr Frederick Treves,³¹ the doctor who befriended him. We also assign poetry that attempts to convey the voice of the Elephant Man from the book, Words for Elephant Man.³² We assume that at least some of the students have already formed their own visual images of John Merrick and we attempt to complicate these depictions. We use the following account about Merrick by Treves: “[He] read his fellow men . . .people's eyes . . . always being stared at . . .the cruel mutterings of the crowd ... . It seemed as if the gaze of the world followed him always.”³³ We also use the passage where Dr Treves sensitively removes all mirrors from Merrick's room, to stimulate discussion about whether this was a kind act.

Since it is well known that fear of mastectomy and its effect on body image has kept many women from seeking appropriate diagnostic testing and care, material is chosen that emphasises the ways various women have come to terms with breast cancer. One especially effective work is the photographic poster called “The Warrior” which shows the writer/poet Deena Metzger after her own mastectomy with her arms flung widely outward exposing the tree-of-life tattoo carved over her mastectomy scar. Used in conjunction with this image Metzger's poem, I Am No Longer Afraid³⁴ makes it clear that this was the body image that put great pressure on the medical community to seek satisfactory, less disfiguring solutions for breast cancer. Readings chosen to illustrate the impact of breast cancer and mastectomy are Robert Hass's one paragraph story, A Story About the Body,³⁵ and selections from Meldin's book, The Tender Bud,³⁶ the true story of an introspective woman psychiatrist who experiences breast cancer, mastectomy, and several reconstructive procedures. Several male students have commented that Meldin's story was especially useful to them because it provided them with a better understanding of how a woman might feel about breast cancer.

The Autobiography of a Face,³⁷ with its arresting cover photo of a woman covering her face with a piece of cloth, provides an excellent vehicle for discussing some of the tragic results of disease and medical therapy. The author, Lucy Grealy, with ruthless self examination, writes a powerful memoir about the premium put on facial beauty and describes her twenty years of living with a distorted self image and undergoing more than thirty reconstructive procedures before coming to terms with her own disfigured jaw as a result of cancer. An excerpt from Ursula Hegi's, Stones from the River,³⁸ a story about an inquisitive, authentic achondroplastic dwarf named Trudi tells of Trudi's real feelings; she is happy, sad, honest, erotic, and spiteful all at once. Whereas a traditional medical text describes an achondroplastic dwarf as having “normal intelligence”, Hegi's story of Trudi mocks medical definition. Trudi is more than just a short-limbed dwarf with a large head, a bulging forehead, and a scooped out nose bridge; she is also a sensitive, caring woman living in Germany in the 1940s who wishes to “tell stories”, “have babies”, and “dance” like the rest of us.³⁹ The “ill body” is also explored as a theme using the work of Frida Kahlo.

During the last section, on mental illness, a lecture based on Michel Foucault's Madness and Civilization⁴⁰ demonstrates how since antiquity the mentally ill have been viewed as objects (for example, spiritual soothsayers, products of the devil, criminals, wards of the state) rather than as human beings. (See table 5) Art shown includes historical depictions of madness, using works such as Theodore Gericault's The Mad Woman (1822), William Hogarth's The Rake's Progress, (1733) and Van Gogh's Potato Eaters, (ca 1885). One recent literary work used to characterise mental illness is an excerpt from Susanna Kaysen's Girl Interrupted⁴¹ where Kaysen relays an “annotated diagnosis” of her own experience in a state mental hospital in the mid-1960s. We also plan to integrate an excerpt from the recent film version of the book. Kaysen argues that “the world of the insane is simply a parallel universe existing alongside this world and resembling it”.⁴² Yellow Wallpaper,⁴³ by Charlotte Gilman is another selection used to emphasise the traumatic experience of a person with mental illness.

STUDENT EVALUATION

As well as attending classes regularly, students also write and revise three journal essay entries that focus on the weekly assignments (of approximately five pages each) and complete a comprehensive final exam covering the literature and art works presented. All materials are taken into consideration when determining final student grades, with writing assignments accounting for 70% of the student's grade, the final exam accounting for 20%, and attendance and participation accounting for 10%.

The writing assignment for the journal essays is to write in a non-technical, personal-experience based paper that “should include discussion of several examples [approximately five] of works of art, items in the popular media, literary works, patient encounters, etc which are relevant to the subjects covered in this class”. The writing assignments are challenging to these medical students because they are used to writing in patients' medical charts and avoiding any discussion of personal feelings. After reading the story, The Fat Lady, many students, including Nate, used their journal essays to reflect on considering whether they approached obese patients differently from other clinical patients. Nate recognised through this exercise that he does to a certain extent blame obese patients for their health problems. Medical students involved in this course share a common, central purpose in writing these essays—to express freely their less-than-objective feelings about a particularly memorable clinical experience. It is obvious that in some way, these students feel safe with their journal writing and are able more closely to consider a clinical encounter (and their role within that experience) and come to some new understanding of themselves, their experiences or the experiences of others, through writing. Their journal writing is an invaluable tool in this particular learning environment because it “open(s) a rhetorical space in which [the students'] silent voices [can] be heard, [opening them] to the influence of other ways of knowing, acting, and being in the world”.⁴⁴

In a final exam, specific questions and literary selections picked vary from semester to semester, but the purpose of the exam remains constant—to give students a series of questions and visual images that challenge their traditional understanding of “objectivity” and “seeing”. As an example, one question last year revolved around having the students explain the significance (in at least three works) of the mirror as a symbolic object that defines one's perception of self. The examination evaluations are based on how accurately students understand the content and artistic value of the works chosen and how well students demonstrate the significance of these works in relation to class topics and themes.

SOME REFLECTIONS

Several important pedagogical lessons have been learned as faculty members have worked together as an interdisciplinary team to teach this course for the last seven years. Firstly, it is important to provide open topic choices for essay assignments to give students the ability to connect with and personalise course materials. On her final journal essay one student wrote of the theme of this course, saying:Over and over, in our readings for this class, the predominant theme is `see me, know me, accept me'. In the case of people dealing with an abnormal body image, be it disfigurement, obesity or disease, this is not just a hope, but also a necessity. Tragically, in spite of more enlightened educational policies, mainstreaming is still a painfully unattainable goal for many.⁴⁵

Another student wrote in her essay of her personal concerns about bearing an abnormal child. A gay male student described his sad experience in a gay bar, where his body image was not seen as attractive enough. An overweight student wrote of the sadness and heartbreak associated with not being seen as attractive to the opposite sex. Although open topic choices contribute to the successful writing/thinking generated through this course, detailed, specific feedback from faculty members (for example, questions/comments about the subject matter) and the option to revise (re-think already written ideas) solidifies student engagement. Revision of journal essays requires medical students to think “differently” about their medical experiences in order to display not only “what they already knew or could see”, but also “what it is that they now know or see”. J L Lemke⁴⁶ argues in “The language of science teaching” that science is expected to “avoid the humanness of everyday language; no personification, no metaphors that call up human, emotionally loaded images . . . the world of scientific language is a world where things simply are as they are”. Michael Polayni⁴⁷ advises that into our conception of the language of scientific knowledge must be incorporated that part which we ourselves necessarily contribute in shaping such knowledge. The writing is especially challenging in this class because medical students are encouraged to consider how they feel during particular medical encounters rather than diagnose what they see; they have to “describe” and “assess” the body as opposed to objectifying it. This naturally encourages them to “contextualise” their notion of body image.

Secondly, faculty members must work together to unify course topics, lecture notes, and grading policies since a cohesive faculty open to change is essential to maintaining a successful course. For example, in this body image course, although each faculty member solely grades one set of the three assigned journal essays, a certain number of journal essay drafts are shared among all three instructors to assure grade consistency. Additionally, faculty members meet each summer after the course is complete to debrief and discuss appropriate syllabus changes.

Other integral activities that make this course successful are things such as 1) assigning students to view community art exhibits (for example, guided tours of art museums; 2) posting a classroom bulletin board for students to bring in timely articles/pictures, and 3) utilising a broad selection of artistic and literary mediums (for example, journal articles, short fiction, recent works, classics, contemporary and classical art, studio art, photography) to guarantee student interest. A final, superficial, yet significant adaptation to the course was the replacement of Robertson Davies's novel The World of Wonders⁴⁸ with Byatt's collection of short stories, The Matisse Stories. Although both works present appropriate and powerful images of the body, The World of Wonders seemed too long and convoluted to be included in an intense four-week interdisciplinary course. Student papers and the final exam demonstrated that the majority of medical students were unable to see how the novel connected to the themes of the course. The Matisse Stories have been well received and have offered the opportunity to present useful information about Matisse and his art.

By allowing medical students the opportunity to talk more personally and metaphorically about the body as a cultural concept we are able, temporarily, to move students into a world where they are more than just “detached” observers of the human body during doctor-patient encounters. By teaching them this lesson, many of these students leave this medical humanities experience wiser about the fact that dealing with the body is much more than an impersonal, get-the-facts transaction. They learn instead that it is possible to confront their own “personal” concept of the body without jeopardising their prior “professional” training. As one medical student put it, students “learn how to disrupt their pure `medical gaze' by honing [their] perceptive abilities”.⁴⁹ The teaching faculty involved in this course believe that the majority of students who participate in this class complete it more acutely aware of the fact that no single human being, even a “good, caring” doctor, can see with an “innocent eye”. The accomplishment of this goal alone justifies faculty participation in the course.