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“We do not store experience as data, like a computer, we story it.”2
“It is difficult to get the news from poems, yet men die miserably every day for lack of what is found there.”3
Poetry and medicine have gone hand in hand since Apollo was the god of both. Literature is a vital element in medicine: biomedical science looks at a slice of experience; literature is as wide as life itself. We would like to invite you on a trip into the depth of life: through literature. Every issue of Medical Humanities will contain a section of original creative writing, offering a window onto the practice, experience, thought and feeling of colleagues, through their writing. Our own and others' stories of practice are our stores of experience, knowledge and skill—embedded in practice. Writing them makes the experience more available to the writers themselves. Reading them, in pages such as this, is a sharing of that wisdom.
Literature takes us out of our own milieu and into another: makes us aware of things we had not expected to see, or were not used to seeing, although they were there all the time, just as Virginia Woolf describes Orlando, who “opened his eyes, which had been wide open all the time”.4
And as Montgomery Hunter says:
“Literature constitutes a source of knowledge. For those to whom the experiences are familiar, narrative is confirming; for those reading about something new, the view of human possibility is enlarged …
“Physicians turn to professional journals for accounts of difficult or unusual cases and new developments that offer hope of altering the plots in old stories of disease. Likewise, in fiction, autobiography, and drama they can broaden their knowledge of human beings not only beyond the textbooks in human behaviour but beyond the ethnic and chronological limits of their own experience. The physician who has read Tolstoy's The Death of Ivan Illych for instance, has imagined a patient's unwilling slide toward death.”5
“Literature has been used in medical instruction to promote moral and ethical reasoning, improve communication between doctor and patient, instill a deeper sense of medical history, explore the therapeutic value of storytelling, advance multicultural perspectives, and increase self-consciousness on the part of medical practitioners.”6 Also, see McLellon and Hudson Jones.7 15
Stories and poems have for some time been included in the Journal of the American Medical Association, The British Medical Journal and The Lancet8, and are the well-thumbed pages. Why do clinicians read and take note of them in these “evidence based practice” times, when there is such an emphasis on the gold standard of the randomised controlled trial? Because doctors and nurses encounter people: their distress, hurts, and traumas; not trials and evidence. And they want to make sense of these—to help them take appropriate and ethical actions. “To make progress with understanding meaning we must look to literature rather than science.”9 And: “Stories are essential as a means of perceiving how scientific knowledge, in its generality, can be applied to individuals in all their particularity”.10
Artistic (creative) writing is offered here because: “Art takes one over a threshold, out of the rut, it questions custom, the ‘taken-for-granted’”.11 And “The function of art in the full extent of its expressions includes the deliberate and subversive challenge to everyday understandings and interpretations of events”.12
“Fiction not only legitimises emotions and aspirations, it also, since the appearance of the novel with its devotion to the minutiae of personal relationships, gives models and patterns of acceptable and unacceptable behaviour. I have certainly noticed that those who never read, or have never read, fiction, tend to be obtuse and insensitive in personal relationships. It does really seem as if the consumption of fiction is a part of the necessary education of modern people in the fine points of human relationships. So many examples are given of how people are, how they may be expected to react, and what the harvest is likely to be.”13
Poems “profoundly alter the man or woman who wrote them”.14
The writing of poetry profoundly alters the writer because the process faces one with oneself. Poetry is an exploration of the deepest and most intimate experiences, thoughts, feelings, ideas: distilled, pared to succinctness, and made music to the ear by lyricism. Dannie Abse is poet, poetry tutor, and medical practitioner: a combination with powerful precedence.15
The process of writing is itself illuminative: “writing taps tacit knowledge—brings into awareness that which we sensed but could not explain”.16 Writing remains on the page in the form the writer put it there: it can be worked upon, developed, rethought. It is taken out of the mind and becomes an object out there for the writer to communicate with. These stages of redrafting are vital for clarification of issues—seeing the patient's point of view for example, or understanding the critical path of events better. So often we blame ourselves for disasters, yet thinking an event through in writing can enable us to perceive the forces which were at work upon us, pushing us to act as we did. Or conversely perhaps the more balanced viewing enabled by writing might mean we can shoulder more responsibility, rather than blaming others.
Writing is, however, a passionate process. But this very expenditure of passion (whether pleasure, hilarity, fear, horror) enables the writer to let go of it, and view the situation without being blinded by the emotion occasioned by the event—become dispassionate.
Writing enables contact with ideas, memories and feelings the writer did not know he or she had, and enables the making of leaps of understanding and connections. The privacy of the writing process can also enable the expression and exploration of issues of which the writer is aware but unable or unwilling otherwise to articulate, communicate and develop. A piece of paper will not frown, groan, or retch, whatever our story.
“We write before knowing what to say and in order to find out if possible.”17
A vilanelle: writing in strict form
“On a muggy Saturday afternoon after a busy week at the health centre, I sat down with two hours to do my homework for the next day's meeting of the reflective writing group for GPs. It's one of my very favourite things—I wonder why I always leave the writing till the last minute?
“I felt exhausted, uncreative and devoid of ideas. Six minutes free writing, recommended by our facilitator as a kind of warm-up,18 produced a long moan about how tired I was. Then I remembered a tutorial on the villanelle I'd read, and wrote this:
A therapeutic villanelle
I'm spending too much time on work, I know The pressure's putting lines upon my face. I'd like to sit and watch the flowers grow.
Sometimes I feel the tears begin to flow: I'm leaden tired, I'm desperate for some space, I'm spending too much time on work. I know!
Do they want blood? Why don't they bloody go? I'll crack if I continue at this pace. I need to sit and watch the flowers grow.
Those piles of paperwork oppress me so, They never seem to shrink, it's a disgrace. I'm spending too much time on work, I know.
If I could take my time and take it slow, If life could be a pleasure, not a race, Perhaps I'd sit and watch the flowers grow.
If I got bored, there's places I could go, I'd stretch my limbs, write poetry, find grace. Must get to spend less time on work—although I might do more than just watch flowers grow.’
When I'd finished it, I felt rejuvenated and alive.
It's always good to express my feelings in writing, but I was surprised to feel so dramatically better. Possibly the challenge of writing in a tight poetic form had a specific chemical effect on my brain (maybe serotonin reuptake inhibition like Prozac, or dopamine release like cocaine).”
Medicine as narrative
The medical process is itself narrative.5–10 Patient and doctor each have a story of experience. The patient goes to the surgery with an illness (chest pains), and walks away with a disease (heartburn). The personal illness story is not lost, but retained alongside the medical one: that these are different needs to be recognised.
Within medical stories of disease patients are too often metonymically reduced—a part standing for the whole—becoming a leg ulcer, or a myocardial infarct, whereas within their own story they retain a dignity of wholeness: the person is ill.
Society, and people's lives, tend to be fragmented in these peri-millennial times: we have lost the family doctors who heard and took care of their patients' stories,19 the priest, the village midwife, granny or auntie always up the road. This fragmentation, and social (as well as medical) metonymic reduction, can lead to a “failure to thrive”, as is only too evident in our areas of urban deprivation. Gaining understanding of the patient's story, as well as the clinician's, can help create a recognisable pattern, enhancing empathetic and ethical understanding of the patient.
Reading and writing literature are pleasurable activities, playful even. Creativity is playful, one of its appeals to audiences and artists (musicians even play their instruments). This does not denigrate art; rather it grows up the role of playing from the purely childish arena, where it has been relegated by our modernist culture. We really learn only when we are happy and enjoying ourselves; the notion that the path of experience and knowledge is rocky and painful has died.
Medicine, nursing, therapy and many other professions are all processes of helping the other to grow. Practitioners cannot support others in growing if they are not growing themselves. If the personal is brought into the professional by an aesthetic process, then the empathy between client and professional must be increased.12 Aesthetic experience can leap over the seeming gap between the personal and the professional self. This can only bring greater unity and wholeness of experience to the practitioners, and greater empathy between them and their clients. Both practitioner and patient will be enabled to grow.
The reading and writing of literature, and the giving of respect to patients' narratives, is neither a romantic project nor an unserious one, but a way of putting the rest of the pieces of the jigsaw back into the picture.
In the beginning was the word. This tends to be forgotten, along with the essential plasticity of our language—there to be played with, to see what it has to offer. In a culture obsessed with measurement, the focus is upon making language express what is known, forgetting that language can tell us what it wants to communicate through us. An appreciation of literature, whether reading or writing, is a letting go of control: allowing language to speak us.
Gillie Bolton is Research Fellow in the Institute of General Practice, Sheffield University Community Sciences Centre, Northern General Hospital, Sheffield S5 7AU.
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